Mala Gupta

Magnetic Resonance Imaging as an Adjunct to Ultrasound in Evaluating Cesarean Scar Ectopic Pregnancy

Cesarean scar pregnancies (CSPs) are a relatively rare form of ectopic pregnancy in which the embryo is implanted within the fibrous scar of a previous cesarean section. A greater number of cases of CSPs are currently being reported as the rates of cesarean section are increasing globally and as detection of scar pregnancy has improved with use of transvaginal ultrasound (TVUS) with color Doppler imaging. Delayed diagnosis and management of this potentially life-threatening condition may result in complications, predominantly uterine rupture and hemorrhage with significant potential maternal morbidity. Diagnosis of a cesarean scar pregnancy (CSP) requires a high index of clinical suspicion, as up to 40% of patients may be asymptomatic. TVUS has a reported sensitivity of 84.6% and has become the imaging examination of choice for diagnosis of a CSP. Magnetic resonance imaging (MRI) has been used in a small number of patients as an adjunct to TVUS. In the present report, MRI is highlighted as a problem-solving tool capable of more precisely identifying the relationship of a CSP to adjacent structures, thereby providing additional information critical to directing appropriate patient management and therapy.

Endoscopic-Ultrasound-Guided Fine-Needle Aspiration and the Role of the Cytopathologist in Solid Pancreatic Lesion Diagnosis

Endoscopic ultrasound (EUS) is the most sensitive imaging modality for solid pancreatic lesions. The specificity, however, is low (about 75%). It can be increased to 100% with an accuracy of 95% by the addition of fine-needle aspiration (FNA). Cytopathology plays an important role. The final diagnosis is based upon the correlation of clinical, EUS, and cytologic features. A close interaction with the cytopathologist is required in improving the diagnostic yield. In this paper, we present an overview of the role of EUS-guided FNA and importance of close interaction with the cytopathologist. Day to day examples of different solid pancreatic lesions have been presented at the end.

Diagnosis of gastric glomus tumour by endoscopic ultrasound-guided fine needle aspiration cytology: a case report.

Dear Editor, Glomus tumour (GT) is a distinct, benign, solitary cellular proliferation that arises from modified smooth muscle cells of the glomus body, a type of neuromyoarterial receptor which plays an important role in the regulation of arterial blood flow. The majority of GTs occur in the deep dermis or subcutis of the upper or lower extremity, where arteriovenous anastomoses are numerous. However, they may also develop at sites at which the glomus body may be sparse or even absent, such as bone and joints, skeletal muscle, soft tissue, mediastinum, trachea, kidney, uterus, vagina and stomach. Although the histopathological features of gastric GT have been well described in the literature, its cytological features, which may help in a definitive preoperative diagnosis, have rarely been described. We report a case of gastric GT diagnosed by endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) cytology supported by cell block immunohistochemistry (IHC), and later confirmed on endoscopic submucosal resection (ESMR). Because they are derived from modified smooth muscle cells, GTs exhibit a similar immunoprofile. Conservative local resection is usually the optimal therapy for gastric GT. However, because of the intramural location, which precludes an endoscopic biopsy diagnosis, and the lack of specific clinical or radiological features to distinguish them from other intramural masses, GTs are commonly diagnosed histologically after either an endoscopic submucosal or radical resection. FNA cytology obtained by EUS can be used for preoperative diagnosis to distinguish GTs from more aggressive gastric tumours, sparing the patient an extensive surgical resection. We came across a 51-year-old man who presented with dyspepsia. An upper gastrointestinal endoscopy (Figure 1) showed a 2.4 9 2-cm, round, hypoechoic and enhancing submucosal lesion in the gastric antrum causing mass effect. The EUS-FNA smears showed cohesive clusters of uniform round cells with ill-defined cytoplasmic borders and scanty amphophilic cytoplasm, admixed with spindleshaped endothelial cells (Figure 2). The nuclei were round with smooth nuclear membranes and evenly distributed dusty chromatin. The cell block showed monomorphic cellular clusters arranged around sinusoidal spaces (Figure 3). The differential diagnoses considered were low-grade neuroendocrine tumour (LGNET), epithelioid gastrointestinal stromal tumour (GIST)/leiomyoma, poorly differentiated carcinoma (PDCA), haemangiopericytoma (HPC), perivascular epithelioid cell tumour (PEComa) and paraganglioma. The cells showed strong immunoreactivity for smooth muscle antigen (SMA; Figure 3, inset) and vimentin, and were negative for desmin, CD34, c-kit (CD117), chromogranin, synaptophysin and pancytokeratin (panCK). The negative neuroendocrine markers and cytokeratin excluded a neuroendocrine neoplasm and PDCA. CD117 and CD34 negativity ruled out GIST and HPC. The desmin ( )/actin (+) immunophenotype was unusual for a leiomyoma, but fitted that of GT, as did the morphology. Subsequently, the diagnosis was confirmed on ESMR. Neither the cytological preparation nor histological sections revealed any features of malignancy, such as mitotic figures, necrosis, high nuclear grade or infiltrative growth pattern. The patient is on follow-up and has been doing well for the last 23 months. DeBusscher demonstrated the presence of glomus bodies in the submucosa and subserosa of the stomach, mainly along the lesser curvature and the posterior wall near the cardia, explaining the selective occurrence of GT in the stomach. Vinette-Leduc and Correspondence Sambit Kumar Mohanty, Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Room 8709, South Towers, 8th Floor, Los Angeles, CA 90048, USA Tel: +516-444-2931; Fax: +310-423-1571; E-mail: sambit.mohanty@cshs.org

Radiology–pathology conference: primary adrenal lymphoma

We present a case of a 62-year-old man with a history of type II diabetes mellitus who presented to our emergency department with back pain and right upper quadrant abdominal pain associated with vomiting and weight loss. A computed tomographic scan of the abdomen and pelvis demonstrated a large adrenal mass, and subsequent biopsy showed primary adrenal lymphoma.

The Accuracy of Endoscopic Ultrasound (EUS)-Guided Fine Needle Aspiration (FNA) for Diagnosing Solid Pancreatic Lesions Using a New 25-Gauge Needle System

The Accuracy of Endoscopic Ultrasound (EUS)-Guided Fine Needle Aspiration (FNA) for Diagnosing Solid Pancreatic Lesions Using a New 25-Gauge Needle System Sammy Ho, Robert Bonasera, Hazar Michael, Bonnie Pollack, James Grendell, Mala Gupta, Martin Feuerman, Simcha Pollack, Frank Gress Introduction: EUS-FNA has enhanced our ability to diagnose pancreatic masses. Most of the published data is based on the use of a 22-gauge needle. The aim of this study was to evaluate our center’s experience with a new disposable 25-gauge needle system in the diagnosis of solid pancreatic lesions.Methods: Our institution began utilizing this FDA approved 25-gauge EUS-FNA needle system (Echotip, Wilson Cook, Winston Salem, NC) in 2/2001. All patients referred for EUS evaluation of solid pancreatic mass between 2/2001 and 12/2002 were reviewed. Patient demographics, clinical history including follow-up, and pathology findings were recorded. Cytopathology was compared with operative histopathology in patients who had surgery. Patients who did not have surgery were followed clinically. Results: A total of 163 patients (mean age 66, 88 M/75 F) underwent EUS-FNA for solid pancreatic lesions using the 25-gauge needle. FNA was consistent with pancreatic malignancy in 48% (78/163) while 45% (74/163) had no evidence of malignancy. In the remaining 7% (11/163), biopsy was inconclusive. No complications were reported. Of the pancreatic cancer patients, 96% (75/78) had adenocarcinoma and 4% (3/78) had other malignancies. In the group with a definitive FNA diagnosis, 14% (23/163) underwent surgery and operative histopathology was compared with FNA cytopathology. There was one falsenegative and no false-positive diagosis; and the sensitivity, specificity, PPV, and NPV were 94%, 100%, 100%, and 86% respectively. In the false-negative case, patient had cytologic evidence of chronic pancreatitis. In patients with an inconclusive FNA, 27% (3/11) had surgery and 2 had adenocarcinoma. The remaining 84% (137/163) of patients who did not undergo surgery were followed clinically. The mean survival for patients with a positive, negative, and inconclusive FNA was 11, 23, and 14 months respectively. Conclusions: 1. EUSFNA using a 25-gauge needle system can accurately and safely provide a cytologic diagnosis of pancreatic masses. 2. The patient who had a false-negative FNA diagnosis had chronic pancreatitis, confirming previous reports that cytologic evaluation of pancreatic tissue in the setting of chronic inflammation can be difficult. 3. Studies with larger sample size and randomized arms are now needed to further assess the accuracy and complication rate of this smaller needle system.

Endoscopic ultrasound guided fine-needle aspiration: What variables influence diagnostic yield?

Endoscopic ultrasound (EUS) guided fine‐needle aspiration (FNA) plays an important role in the diagnosis of various lesions. We sought to determine factors that influence the diagnostic yield of EUS–FNA, specifically, the presence of a cytopathologist, FNA site, and the endoscopists skill.