P. Lohela

ULTRASOUND-GUIDED FINE-NEEDLE ASPIRATION CYTOLOGY OF NON-PALPABLE SUPRACLAVICULAR LYMPH NODES IN SARCOIDOSIS

Purpose: The aim of this prospective study was to determine the incidence of enlarged supraclavicular lymph nodes by US and the diagnostic yield of US-guided aspiration cytology in the diagnosis of sarcoidosis. Methods: During a 54-month period, all consecutive patients with a clinical suspicion of sarcoidosis underwent supraclavicular US at the Kiljava Hospital, Finland. All patients with enlarged supraclavicular lymph nodes underwent US-guided fine-needle aspiration biopsy (FNAB) of the lymph node. Results: Of a total of 250 patients, 27 (10.8%) had enlarged supraclavicular lymph nodes at US. All these were non-palpable at clinical examination. The cytological specimen was quantitatively sufficient in 25 of the 27 cases (93%). In 22 (88%) of these, the cytological diagnosis was granulomatous inflammation suggestive of sarcoidosis. Three aspirates yielded reactive hyperplasia and 2 specimens were insufficient. No complications occurred. The patients were followed for 2–42 months (mean 19 months), and the diagnosis of sarcoidosis was confirmed clinically in all cases. Conclusion: Supraclavicular US detects non-palpable enlarged lymph nodes in 1/10 of the patients with suspected sarcoidosis. In this subgroup of patients, US combined with aspiration cytology may give cytological evidence of granulomatous disease similar to sarcoidosis and more invasive diagnostic methods can be avoided.

Ultrasound-Guided Aspiration Cytology of Enlarged Lymph Nodes

Cytological results of US-guided fine needle aspiration biopsies of enlarged lymph nodes from 179 patients were analyzed retrospectively. The final diagnoses were benign lymphadenopathy in 90 cases, metastasis in 56, and malignant lymphoma in 33 cases. The material was sufficient for cytological analysis in 174 cases (97.2%). Correct diagnosis of malignant (C IV—V) and benign (C I—II) lymphadenopathy in the whole material was possible in 80 percent of cases. Correct subtyping of lymphoma was possible in 63.6 percent of the cases. There was one (0.6%) false positive (C IV), 6 (8.5%) false negative (C I—II), and 24 (13.8%) suspicious (C III) cytological findings. All but one of the false negative cytological findings were from superficial lymph nodes. No complications occurred. US-guided lymph node aspiration biopsy is safe and accurate in the superficial, anterior mediastinal, abdominal, and retroperitoneal lymphonodal areas. Lymph nodes with a C 0 cytological result should undergo rebiopsy and suspicious (C III) or clinically doubtful cases should be referred for a surgical biopsy.

Parathyroid adenomas: pre-operative localization with ultrasound combined with fine-needle biopsy.

Sixteen patients with biochemically proven primary hyperparathyroidism (PHPT) underwent ultrasonography (US), fine-needle aspiration (FNA) for cytologic sampling (n = 9), or intact parathormone assay (n = 3) before operation (n = 15) in order to determine the accuracy of the methods. Pre-operative US was found sensitive (100 per cent), but two thyroid lesions were initially diagnosed as parathyroid tumours by US (i.e. false positives). Parathyroid cells were detected in six cytologic specimens, one sample was insufficient and another inconclusive, while one was diagnosed as thyroid tissue. Parathormone assay revealed a high hormone content in all three patients who underwent the procedure. We conclude that US is sufficiently sensitive to detect enlarged parathyroid tumours. Specificity can be improved by US-guided FNA for cytology or parathormone assay prior to neck exploration.

Diagnosis of diffuse lung disease by cutting needle biopsy

The results of 15 consecutive automated cutting needle (1.2 mm, n = 14; 2.0 mm, n = 1) biopsies of diffuse lung manifestations are presented. Sufficient material for histologic analysis was obtained in 13 of 15 specimens (87%) and a specific diagnosis was obtained in 11 of 14 patients (79%). The tissue specimen confirmed the clinically probable lung disease in 6 patients, gave a new, unsuspected, diagnosis in 2, and resolved a differential diagnostic problem in 3 patients. One pneumothorax after a 2.0-mm needle biopsy necessitated catheter drainage. We conclude that percutaneous lung biopsy with the automated biopsy device mounted with a 1.2-mm needle yields a histologic diagnosis with high accuracy in interstitial and alveolar lung changes, reducing the need for more invasive methods such as open lung biopsy.

Nonparasitic splenic cysts. Ultrasonographic features and follow-up.

Sixty-three patients with splenic cysts, multiple in 7 cases, were reviewed. Only 3 patients had a history of previous abdominal trauma. The cysts ranged in size from less than 1 cm to 15 cm. They were anechoic in 40 patients, hypoechoic in 16, isoechoic in 4, mixed in one, and in 2 cases the echogenicity could not be assessed due to thick marginal calcifications. The echogenic cysts were larger than the anechoic ones and frequently calcified, and the findings at surgery, fine-needle aspiration biopsy and follow-up suggested the echogenicity to be related to a fresh or previous episode of intracystic hemorrhage. Initially, surgical treatment was undertaken on 10 patients, electively in 9 cases and due to cyst rupture in one. At follow-up (n = 37), the size of the cyst had increased markedly over several years in only 2 patients, necessitating delayed surgery in one. Routine follow-up of asymptomatic splenic cysts was of no clinical value.

Pleuro-pulmonary aspergillosis : US and US-guided biopsy as an aid to diagnosis

We reviewed the US findings and the diagnostic yield of fine-needle aspiration biopsy (FNAB) for cytologic and microbiologic samples in 4 patients with pulmonary or pleural aspergillosis. All 3 apical Aspergillus abscesses were round, hypoechoic with irregular margins and one contained echo-densities with shadowing consistent with air. One pleural empyema was oval and hypoechoic. Cytology suggested inflammation in all cases and Aspergillus hyphae were detected in 2 of 4 aspirates. Culture of the aspirate was positive for Aspergillus in 3 of 4 cases, while one diagnosis was made after surgery. No complications occurred. Apico-pleural Aspergillus lesions are suitable targets for US-guided FNAB, thus avoiding more invasive methods. Our results suggest wider use of this procedure.

Pleuro-Pulmonary Aspergillosis

We reviewed the US findings and the diagnostic yield of fine-needle aspiration biopsy (FNAB) for cytologic and microbiologic samples in 4 patients with pulmonary or pleural aspergillosis. All 3 apical Aspergillus abscesses were round, hypoechoic with irregular margins and one contained echo-densities with shadowing consistent with air. One pleural empyema was oval and hypoechoic. Cytology suggested inflammation in all cases and Aspergillus hyphae were detected in 2 of 4 aspirates. Culture of the aspirate was positive for Aspergillus in 3 of 4 cases, while one diagnosis was made after surgery. No complications occurred. Apico-pleural Aspergillus lesions are suitable targets for US-guided FNAB, thus avoiding more invasive methods. Our results suggest wider use of this procedure.

Nonparasitic Splenic Cysts

Sixty-three patients with splenic cysts, multiple in 7 cases, were reviewed. Only 3 patients had a history of previous abdominal trauma. The cysts ranged in size from less than 1 cm to 15 cm. They were anechoic in 40 patients, hypoechoic in 16, isoechoic in 4, mixed in one, and in 2 cases the echogenicity could not be assessed due to thick marginal calcifications. The echogenic cysts were larger than the anechoic ones and frequently calcified, and the findings at surgery, fine-needle aspiration biopsy and follow-up suggested the echogenicity to be related to a fresh or previous episode of intracystic hemorrhage. Initially, surgical treatment was undertaken on 10 patients, electively in 9 cases and due to cyst rupture in one. At follow-up (n = 37), the size of the cyst had increased markedly over several years in only 2 patients, necessitating delayed surgery in one. Routine follow-up of asymptomatic splenic cysts was of no clinical value.

Gallbladder Necrosis following Hepatic Artery Embolization

During recent years the percutaneous puncture and drainage of the gallbladder under ultrasound (US)-guidance has become an established procedure. It is primarily indicated in patients who do not respond to medical therapy and who are poor surgical candidates (3, 6–8). In addition, stone dissolution, fragmentation and removal are indications for percutaneous cholecystostomy (8).Gallbladder necrosis is a rare complication of transcatheter embolizations (2). We have successfully treated a patient with gallbladder necrosis following embolization of a bleeding gastroduodenal artery by US-guided cholecystostomy. This may be a new indication for percutaneous gallbladder procedures. To our knowledge no previous reports exist on this subject.

Gallbladder Necrosis following Hepatic Artery Embolization: A new indication for percutaneous US-guided cholecystostomy?

During recent years the percutaneous puncture and drainage of the gallbladder under ultrasound (US)-guidance has become an established procedure. It is primarily indicated in patients who do not respond to medical therapy and who are poor surgical candidates (3, 6–8). In addition, stone dissolution, fragmentation and removal are indications for percutaneous cholecystostomy (8).Gallbladder necrosis is a rare complication of transcatheter embolizations (2). We have successfully treated a patient with gallbladder necrosis following embolization of a bleeding gastroduodenal artery by US-guided cholecystostomy. This may be a new indication for percutaneous gallbladder procedures. To our knowledge no previous reports exist on this subject.