Guided Fine Needle Aspiration

Conclusions: To the best of our knowledge, this is a very rare presentation of an ocular malignant melanoma with an isolated pancreatic metastasis causing symptomatic biliary obstruction. Endoscopic ultrasound-guided fine- needle aspiration has proven to be the best method to diagnose solid pancreatic lesions. In this particular case, cytology was essential in confirming the diagnosis and guiding the most adequate therapy, which was a pancreatic resection, ocular exenteration of the melanoma, followed by adjuvant chemotherapy.

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare neoplasm that has been reported to account for between 0.17% and 2.7% of all non-endocrine tumors of the pancreas. It is usually seen in young women and is usually asymptomatic. The lesion is generally large (2.5cm to 10cm) and encapsulated and frequently contains vary- ing amounts of necrosis, hemorrhage, calcification and cystic changes [1]. Because SPN is rarely aggressive, has low-grade malignant potential and carries an excellent prognosis after complete resection, it should be differenti- ated from other, more aggressive tumors, such as adeno- carcinoma and endocrine tumors [2]. SPN is an ideal pancreatic tumor for treatment by minimally invasive surgery. Therefore, pre-operative accurate diagnosis is very important. Endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA) has recently been established as a modality for use in the diagnosis of pancreatic mass-related lesions.

Methodology: Sixteen prospectively studies have been performed using endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) in patients with submucosal hypoechoic tumors (according to the results of previous gastroduodenoscopy) with continuity to proper muscle layer suspected as leiomyoma of upper gastrointestinal tract. All cases for the final diagnosis underwent surgery (n = 16). Additionally, immunophenotyping of specimens obtained by EUS-FNA and surgical resection specimens have been compared.

protein was 283 μg/L (normal range ≤ 20 μg/L), but the levels of other tumor markers, such as carcinoembryonic antigen and carbohydrate antigen 19-9, were within the normal limits. The patient was non-reactive in HIV serology and his tuberculin test was strongly positive. A chest CT scan showed multiple calcification foci in right pulmonary lobe, bilateral hydrotho- rax (obvious on the right), mild hydropericardi- um. US scan of abdomen revealed multiple flaky or nodular asymmetrical hypoecho nod- ules in the capsule of right hepatic anterior and posterior lobe with an unclear boundary, multi- ple unequal-sized partly interfused hypoecho nodules of the posterior peritoneum, moderate liquid dark area (Figure 1). Abdominal plain CT revealed multiple hypodense lesions of the liver, multiple retroperitoneal lymphadenecta- sis in the peritoneal cavity, ascites, splenomeg- aly (Figure 2). Taken CT, US image findings, clinical manifestation and past medical history into consideration, the diagnosis of hepatocel- lular carcinoma with intrahepatic metastasis was suspected. In order to establish the diag- nosis, liver specimens were obtained by CT- guided fine needle aspiration biopsy (FNAB). Histopathological examination showed fea-

Abstract: Background: False negative (FN) or false positive (FP) results of thyroid ultrasound-guided fine needle aspiration (US-guided FNA) cause missed diagnosis of thyroid cancer or unnecessary thyroidectomy. Purpose: To explore the impact of Hashimoto’s thyroiditis (HT) on the diagnostic efficacy of US-guided FNA and to analyze the differences in diagnostic efficacy between US-guided FNA and thyroid ultrasonography (US) in patients with HT. Method: Medical records were reviewed retrospectively. Patients with and without Hashimoto’s thyroiditis (HT) were included in the exposure and non-exposure group, respectively. Results: HT was not an independent risk factor for thyroid cancer. The percentage of undetermined results of US-guided FNA (Bethesda I, III, IV) in the exposure group was significantly higher. The US-guided FNA’s diagnostic sensitivity, specificity, and accuracy were significantly lower, and FP rate (FPR) and FN rate (FNR) were higher in the exposure group. In the exposure group, US tended to give higher diagnostic sensitivity, accuracy, PPV, NPV, and lower FPR and FNR. Receiver operating characteristic (ROC) curve analysis showed that, in the exposure group the diagnostic efficacy of thyroid US was significantly higher than of US-guided FNA. Conclusion: HT tends to cause undetermined results and elicit lower diagnostic performance of US-guided FNA. In patients with HT, the diagnostic efficacy of thyroid US is, at least, not inferior to US-guided FNA.

Background: FNAC has become an established investigation in the diagnosis of accessible and palpable lesions. Most of the intra-abdominal masses are non-palpable and even if they are palpable, the idea of their size and shape and the extent of the lesion is not possible. Therefore, various imaging modalities like ultra-sonography, computed tomography and fluoroscopy are used as a guide for fine needle aspiration nowadays. Objectives of this study were to assess the utility of image guided fine needle aspiration cytology in the diagnosis of non-palpable intra-abdominal lesions. To study the cytomorphological features of these lesions. To evaluate the sensitivity, specificity and diagnostic accuracy of image guided fine needle aspiration cytology of these lesions.

Background: The liver is a common site for primary and secondary tumors; most often from malignant tumors within the abdomen and from extra-abdominal primary malignant neoplasm, but also for sarcomas and lymphomas. The main indication of fine-needle aspiration cytology (FNAC) of the liver is diagnosis of single or multiple space occupying lesions. This study aims to evaluate the cyto-morphology of primary and secondary neoplasms of liver and non-neoplastic conditions in the smears of ultrasound guided fine needle aspiration of SOL of liver, to evaluate the cytomorphologic features and to evaluate the erroneous diagnosis when compared with cell block preparation of aspirate (tissue diagnosis).

Background and Aims -Transesophagealbronchoscopic ultrasound-guided fine needle aspiration (EUS-B-FNA), performed using an endobronchial ultrasound (EBUS) bronchoscope is a useful modality for diagnostic evaluation of mediastinal lymphadenopathy. Most of the literature on EUS-B- FNA is limited to adults, with limited studies describing safety and utility in children. We describe a case series of EUS-B-FNA in the pediatric population, with a comprehensive review of literature. Methods - Three children under the age of 8 years underwent EUS-B-FNA of mediastinal lymp- nodes, with microbiological and histopathological evaluation.

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare tumor. This neoplasm usually arises as a single mass; multicentricity is exceptionally rare. We report the preoperative diagnosis of multicentric SPNs by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). A 32-year-old woman presented to the hospital with a pancreatic tumor that was detected on abdominal echography. Contrast-enhanced computed tomography (CT) scans revealed a 5-mm low-density mass in the body of the pancreas and a 10-mm mass in the tail of the pancreas. Magnetic resonance imaging (MRI) also revealed two tumors in the body and tail of the pancreas. On endoscopic ultrasonography (EUS), two indistinct and heterogeneous echogenic masses were found, and EUS-FNA was performed for each of these tumors. Cytological analysis revealed that the two masses were highly cellular with papillary groups of small, uniform, oval cells surrounding a fibrovascular core. Immunohistochemistry was positive for α -1 antitrypsin, vimentin, neuron-specific enolase (NSE), CD10, and progesterone receptor. These features confirmed the preoperative diagnosis of multicentric SPNs. The patient underwent laparoscopic distal pancreatectomy with splenectomy. The final pathologic diagnosis was multicentric SPNs. During 2 years of follow- up, she has not developed any recurrence.

EUS-FNA was successfully performed in all 37 pa- tients after an average of 2.4 needle passes (range: 2–4). The final diagnosis was obtained in 35 (94%) cases: 30/ 35 confirmed the clinical suspicion for PM [lymphoma (6), colon (4), renal clear cell (4), lung (3), breast (2), leiomyosarcoma (2), stomach (1), esophageal (1), gallblad- der (1), hepatocellular carcinoma (1), mesothelioma (1), myeloma (1), ovarian (1), rhabdomyosarcoma (1), and melanoma (1)]. A primary pancreatic neoplasm was con- firmed in 3 cases [IPMN (1), NET (1) and adenocarcin- oma (1)], and in 2 cases a pancreatic pseudotumour was found (pancreatic blastomycosis and tuberculosis). In the remaining 2 cases, the diagnosis obtained by EUS-FNA was chronic pancreatitis, but surgical resection confirmed a PM (gastric and lung cancer) (Additional file 1).

First, and as presented above, US-guided axillary FNA was not able, in our series, to classify patients according to the number of involved lymph nodes (> 2 or ≤ 2). Al- though patients with a positive US-FNA do have signifi- cantly more positive lymph nodes upon axillary dissection than those with SLNB, as shown by van Wely and colleagues in their comprehensive meta-analysis [19], we and others [4] have shown that close to half of patients with a positive US-FNA end up with two or less positive axillary lymph nodes following dissection. More- over, a non-negligible proportion of these patients have a low-volume metastatic nodal disease (< 5 mm) [20], and performing an ALND on such patients, irrespective of the Z0011 trial, remains controversial [20, 21]. As stated by Lloyd et al., axillary ultrasound did detect a higher axillary tumor burden than in patients who underwent sentinel lymph node biopsy; however, 40% of the axillary ultrasound group had two or fewer lymph nodes with macrometastasis after axillary lymph node dissection and hence were subject to overtreatment [22]. Moreover, 78% of women with invasive breast carcinoma measuring 2 cm or less who also had one abnormal lymph node on axillary ultrasound were shown to have two or fewer involved nodes upon axillary lymph node dissection and would have benefited from sentinel lymph node biopsy and avoided axillary surgery, as shown by Puri et al. [23].

Background: Fine needle aspiration (FNA) is the standard of care for the diagnostic work-up of thyroid nodules but despite its proven utility, the non-diagnostic rate for thyroid FNA ranges from 6-36%. A non-diagnostic FNA is problematic for the clinician and patient because it can result in repeated procedures, multiple physician visits, and a delay in definitive treatment. Surgeon-performed FNA has been shown to be safe, cost-effective, as accurate as those performed by other clinicians, and has the added benefit of decreasing wait times to surgery. Several studies have examined rates and factors that may be predictive of a non-diagnostic cytology in non-surgeon FNA, but none have evaluated this in surgeon-performed thyroid FNA. If these factors are unique in surgeon-performed vs. non-surgeon performed thyroid FNA, then patients may be more appropriately triaged to FNA by alternate clinicians.

further complications were experienced as a result of the foreign body being imbedded in the lymph node. Similarly, during the EBUS-TBNA of a subcarinal lymph node, ¨ Ozg¨ul et al. [9] experienced the breaking of a 22-gauge needle after the third passage, leaving an 11 mm fragment in the airways. The authors noted that the texture of the lymph nodes was normal and they did not have difficulties in reaching them. A manufacturing error was suspected. The needle could not be retrieved on the subsequent urgent bronchoscopy, as it was no longer in the airways. It was later located in the transverse colon on an abdominal X-ray. The patient remained asymptomatic and no complications were observed on follow-up. Dhillon and Yendamuri [10] also had a comparable experience during an EBUS-guided TBNA for suspicious mediastinal lymphadenopathy. The needle broke from its sheath and protruded outwards. Fortunately, the broken needle was still attached to the rest of the apparatus and was thus removed in one piece without any remnants left in the patient. Once again, standard endoscopic techniques were used and there was only a single aspiration done. The texture of the tissue was not described.

Currently, poor cellularity of the aspirates obtained through EUS-FNA is a common cause of the lack of a diagnosis, which may result in repeated procedures and a delay in reaching a diagnosis [22, 23]. Dry and wet suction tech- niques were developed to improve the performance of as- pirating solid lesions in the intra-abdomen and mediastinum, but neither has yet been recommended as a standardized EUS-FNA suction technique. Applying the DRST is related to more cellularity during tissue acquisition but more blood contamination may occur and thus affect the overall quality of the specimen [18]. By studying a three-dimensional computational fluid dynamic model, it has been suggested that because water is a less compress- ible fluid than air a water-filled needle (wet technique) is

The study revealed that image guided FNAC is an excellent diagnostic modality and shows high accuracy and high sensitivity in diagnosing retroperitoneal lesions with minimal complications. With the use of FNAC, an accurate pre- operative diagnosis of retroperitoneal lesions is possible and the need for surgical exploration may be obviated in a large number of cases facilitating initiation of appropriate therapy as well as saving manpower and cost of hospitalisation.

Graves' disease and three subjects had multinodular goit- ers. All hyperthyroid subjects had hypoactive nodules on thyroid scintigraphy. In the palpation group 4 (2%) biop- sies were malignant, 141 (70%) benign and 2 (1%) inde- terminate. In the ultrasound-guided group 5 (3%) biopsies were malignant, 147 (80%) benign and 9 (5%) indeterminate. The rate of malignancy was similar whether or not fine-needle aspiration biopsy was per- formed manually or under ultrasound guidance. Signifi- cantly more patients had benign and indeterminate results in the USG-guided group. Twenty-seven percent (55/202) of palpation-guided and 13% (23/184) of ultra- sound-guided biopsies were inadequate for evaluation ( χ 2:12.95, df: 1, p = 0.0003). Eighteen subjects from the pal- pation- and 23 subjects from the ultrasound-guided group underwent thyroid surgery. In the palpation group, his- topathology showed two papillary thyroid carcinomas which were also malignant in prior cytology and were true positives. There were no false negative results in palpa- tion-guided biopsies. There were 16 nodules that were benign in histopathology. Twelve of them were classified as benign, three as inadequate (a total of 15 true nega-

pancreatic body or pancreatic tail, except for a case with pancreatic head cancer who did not undergo surgery, and two cases where there was no description. This was prob- ably because the puncture route is included in the resec- tion range for pancreatic head cancer. In 3 of 18 cases, including our 2 cases, needle tract seeding was detected during surgery. Therefore, intraoperative assessment for gastric wall metastasis is important as well as postopera- tive assessment, and if surgeon suspects gastric wall me- tastasis intraoperatively, partial gastrectomy should be performed without hesitation. In these reported cases, the median period until the gastric wall metastasis after EUS- FNA is 21 months, but it occurred only 10 days in the shortest case [5]. As shown in our case 2, needle tract seeding after EUS-FNA cannot be controlled even after chemoradiotherapy.

area of the target. It was particularly important to thor- oughly monitor the needle tip during the entire proced- ure. After the needle tip was placed in the appropriate position within the target, the sampling commenced using back-and-forth movements and a mixed sampling technique (that is, capillary sampling at first, followed by gradual aspiration). No local anesthesia was used in US- FNA for any patient.

Ultrasound Guided Fine Needle Aspiration (USFNA) is a cost-effective and highly reliable procedure used to evaluate and guide the management of thyroid nodules [1]. The Bethesda System for Reporting Thyroid Cytopa- thology (BSRTC) has resulted in standardization, repro- ducibility and improved clinical significance of thyroid USFNA. It is comprised of the following six categories: B1, non-diagnostic; B2, benign; B3, Atypia of undeter- mined significance or follicular lesion of undetermined significance; B4, (suspicious for) Follicular neoplasm; B5, Suspicious for malignancy; B6, malignant. Management decisions are not straightforward when the USFNA dem- onstrates a Bethesda score of either category III (B3) or IV (B4) [2–6]. In those instances, it is not uncommon for some patients to undergo diagnostic hemi-thyroidectomy to obtain a definitive diagnosis, while others prefer a more conservative approach and opt for a repeat USFNA (r-USFNA). However, none of these scenarios are ideal. A hemi-thyroidectomy is rarely the procedure of choice for a thyroid nodule: it is either unnecessary (in the event of a benign lesion) or inadequate (in the event of a malignant lesion). Likewise, the benefit of repeat USFNA is unclear with respect to its contribution to patient management. If the r-USFNA results in Bethesda II (B2), Bethesda V (B5) or Bethesda VI (B6), then management recommendations are more clear and the test is deemed to be useful. How- ever, if the test yields a Bethesda I (B1), B3, or B4, then r- USFNA is not helpful. The aim of this study is to assess the effectiveness of repeat USFNA in the management of indeterminate thyroid nodules (B3 and B4) by evaluating the likelihood of obtaining a definite diagnosis. Moreover, this investigation assesses the usefulness of r-USFNA in the prevention of completion hemi-thyroidectomies in pa- tients with initial B3 or B4 diagnoses.

Abstract: Endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA) is currently considered the procedure of choice for evaluating mediastinal and hilar lymph nodes in patients with non-small-cell lung carcinoma. In this setting, it is a minimally invasive procedure that can be used to simultaneously diagnose, stage, and obtain cellular material for ancillary studies. Additionally, EBUS-FNA can also be used to triage and diagnose many other mediastinal pathologic processes, such as metastatic malignancy from nonpulmonary origins, lymphoma, and granulomatous lymphadenopathy. At a time when EBUS-FNA is considered the optimal choice for many neoplastic and nonneoplastic conditions of the mediastinal lymph nodes, it has become increasingly important for pathologists to familiarize themselves with the nuances of this procedure. The primary focus of this review is to explore the advantages, adequacy issues, and potential pitfalls of EBUS-FNA, paying particular attention to the situations that may adversely affect patient management.