Rebecca Lai

Endoscopic Ultrasound-Guided Fine-Needle Aspiration Cytology Diagnosis of Solid-Pseudopapillary Tumor of the Pancreas A Rare Neoplasm of Elusive Origin but Characteristic Cytomorphologic Features

Clinical histories, endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) material, and immunohistochemical stains performed on cell block samples of 6 solid-pseudopapillary tumors of the pancreas (SPTPs) were reviewed in the cases of 5 females (13-58 years) and 1 man (57 years); all had abdominal pain. Preliminary cytologic diagnoses at endoscopy included 1 SPTP 2 low-grade neoplasms, and 3 pancreatic endocrine tumors. Variable numbers of branching fragments with central capillaries and myxoid stroma were seen in the smears of 5 of 6 cases but were more apparent in the cell block material of all cases. The cells had bland nuclear features and rare grooves. Extensive necrosis was noted in 1 case and rare mitotic figures in 1. SPTPs showed strong cellular immunoreactivity for vimentin and focal weak keratin reactivity. Neuron-specific enolase, alpha1-antitrypsin, and alpha1-antichymotrypsin stains performed in 2 cases were strongly positive. Subsequent surgical resection confirmed all diagnoses. EUS-guided FNA diagnosis of SPTP is accurate. The characteristic branching papillae with myxoid stroma are best seen in cell block slides. Clinical setting, cytomorphologic features, and immunostains of the cell block help distinguish SPTP from pancreatic endocrine tumors, acinar cell carcinoma, and papillary mucinous carcinoma.

Intraductal Papillary-Mucinous Neoplasm of the Pancreas The Findings and Limitations of Cytologic Samples Obtained by Endoscopic Ultrasound-Guided Fine-Needle Aspiration

All clinically and ultrasonographically suspected examples of intraductal papillary-mucinous neoplasm (IPMN) aspirated during a 17-month period were reviewed and analyzed for follow-up. We identified 18 cases of suspected IPMN in patients 52 to 87 years old. All patients had dilated pancreatic ducts, with 3 showing sonographically apparent intraductal papillary lesions; 5 had adjacent cystic or solid pancreatic masses. Cytologic preparations showed thick, glistening, viscid, abnormal mucus in all cases. Aspirates from 13 lesions (72%) were acellular or sparsely cellular, but entrapped single or loosely cohesive neoplastic cells were identified in 16 cases (89%). Goblet cell morphologic features were common (6/18 [33%]), but papillary clusters and dysplastic changes were infrequent (3 [17%] each). In keeping with current therapeutic thinking, confirmatory histologic follow-up was available for only 4 patients (22%), as most people with lesions clinically, sonographically, and cytologically consistent with IPMN are elderly and often have comorbid conditions. Although endoscopic ultrasound-guided fine-needle aspiration has important limitations, gross and cytologic findings can aid in confirming the suspected diagnosis, and integration of complete clinical, sonographic, and cytologic information may be the best way to reach the most accurate diagnosis possible.

Endoscopic Ultrasound–Guided Fine-Needle Aspiration Findings of Gastrointestinal Leiomyomas and Gastrointestinal Stromal Tumors

True leiomyomas of the gastrointestinal system are rare but remain the most common mesenchymal tumors of the esophagus. It has become important to distinguish these tumors from gastrointestinal stromal tumors (GISTs) because the neoplasms have different prognoses and treatment options. We describe and compare clinical findings and the following fine-needle aspiration (FNA) features of 9 gastrointestinal leiomyomas and 19 GISTs sampled with endoscopic ultrasound: overall cellularity, cell group features, cell shape and cytoplasmic features, nuclear characteristics, background, cell block features, and immunohistochemical results. Gastrointestinal leiomyomas and GISTs have different clinical and cytologic features that help pathologists distinguish these tumors, and the immunohistochemical findings that help define these lesions can be derived readily from cell block material obtained by endoscopic ultrasound-guided FNA.

A limited immunocytochemical panel for the distinction of subepithelial gastrointestinal mesenchymal neoplasms sampled by endoscopic ultrasound-guided fine-needle aspiration.

We studied the use of immunocytochemical analysis with material procured by endoscopic ultrasound-guided fine-needle aspiration (EUS-guided FNA) for the diagnosis of subepithelial intramural gastrointestinal (GI) mesenchymal neoplasms (SIGIMNs). We identified all EUS-guided FNA specimens of SIGIMNs that had undergone immunocytochemical analysis. Results were compared with follow-up histologic diagnoses. There were 95 aspirates that were diagnosed as GI mesenchymal tumors (GI stromal tumors [GISTs], n = 46), leiomyomas (n = 38), peripheral nerve sheath tumors (n = 5), and other neoplasms by cytologic examination. Immunoreactivity with antibodies to CD117 always predicted GIST at follow-up; 15 of 16 cases immunoreactive with antibodies to CD34 were found to be GISTs at follow-up. Strong immunoreactivity with antibodies to smooth muscle actin or desmin usually predicted a leiomyoma at follow-up aside from a single glomus tumor and a case with apparent nonneoplastic smooth muscle contaminant. When sufficient material is present, immunocytochemical analysis used with material obtained by EUS-guided FNA is highly predictive of final pathologic diagnosis.

The utility of EUS-guided FNA in the diagnosis of metastatic breast cancer to the esophagus and the mediastinum

BACKGROUND Breast cancer can metastasize to the esophagus and the mediastinum. EUS-guided FNA (EUS-FNA) is being used increasingly as a less invasive alternative to mediastinoscopy for procuring a tissue diagnosis of mediastinal disease and may be useful for the diagnosis of breast cancer metastatic to the esophagus and the mediastinum. METHODS Twelve women (age range 54-82 years) with a history of breast cancer presented with dysphagia or other symptoms between 1 and 15 years after initial diagnosis and treatment. CT and endoscopy with biopsies suggested a mediastinal mass or lymphadenopathy with extrinsic esophageal compression but failed to provide a tissue diagnosis. EUS-FNA was performed for diagnosis. RESULTS Cytologic evaluation of specimens obtained by EUS-FNA confirmed breast cancer metastases in 11 of 12 patients (91%). Recurrent disease was found in intramural masses and periesophageal lymph nodes. No complication resulted from any EUS-FNA procedure. CONCLUSIONS EUS-FNA is safe and effective for the diagnosis of breast cancer metastases to the esophagus and the mediastinum. EUS-FNA may be useful as a first-line method of evaluation when breast cancer metastasis to the esophagus and the mediastinum is suspected.

EUS-Guided Needle Aspiration (EUS-FNA) in Subepithelial Intramural GI-Tract Masses (SIGIM): Results in 105 Lesions

EUS-Guided Needle Aspiration (EUS-FNA) in Subepithelial Intramural GI-Tract Masses (SIGIM): Results in 105 Lesions Shawn Mallery, Rebecca Lai, Ricardo Bardales, Edward Stelow, Steven Debol, Michael Stanley Background: SIGIMs occur anywhere in the GI tract and may be benign or malignant. Forceps biopsy at EGD is low yield and diagnosis based solely onEUSappearance may be misleading. Experience with EUS-FNA of these lesions is limited to small series and specific diagnoses. Objectives: To assess a)the diagnostic yield of EUS-FNA in SIGIMs of different echogenicities and b)the ability of EUSFNA to obtain sufficient tissue for immunohistochemisty (IHC) when relevant. Methods: EUS-FNA was attempted in all pts undergoing EUS evaluation of SIGIMs. FNA was performed using 22, 19 or 25 ga needles depending upon available technology. Experienced cytopathologists performed on-site interpretations to assess adequacy. Extrinsic compressions, strictures and thickfold gastropathies are not included. Results: 101 pts with 105 lesions had FNA between 6/1998 and 12/2003. Repeat FNA was performed in 5 lesions (total 110 FNAs: 57 stomach, 40 esoph, 10 duod, 3 colon). There were 12 intramural cysts (6 anechoic, 6 hypoechoic): none yielded diagnostic cytology (all yielded fluid, 7/12 were grosslymucoid). 93 solid lesions were aspirated and results shown in the table below. Repeat FNAwas diagnostic in 2 of 4 hypoechoic masses, leading to overall yield of 83% for hypoechoic lesions. EUS-FNA identified 9 carcinomas (7 metastatic, 2 primary esophageal); 59 mesenchymal neoplasms (37 GIST, 12 leiomyomas, 1 glomus tumor, 2 peripheral nerve sheath tumors, 1 granular cell tumor, 1 lipoma, 5 unspecified spindle cell tumors) and 1 pseudocyst. When IHC was needed based on initial smear results, adequate paraffin-embedded material was present in 79%.Among 24 non-dx cases, 4 had characteristic EUS features for lipoma, 4 had EGD/EUS features suggesting pancreatic rest, 2 were later proven GIST, 1 proven granular cell tumor, 1 proven Brunner’s adenoma and 12 remain unknown. Conclusions: The yield of EUS-FNA for solid, hypoechoic intramural tumors was excellent. Sufficientmaterial for IHCwas often obtainedwhen needed. The yield of FNA for suspected lipomas or pancreatic rests was very low. Diagnostic cytology was not obtained in intramural cysts (suspected duplication cysts) but FNA established their cystic nature. Carcinoma was diagnosed in 9%of solid lesions.

A Prospective Evaluation of Tandem EUS and ERCP as a Single Procedure

A Prospective Evaluation of Tandem EUS and ERCP as a Single Procedure Jake Matlock, Shawn Mallery, Rebecca Lai, Martin Freeman BACKGROUND: EUS and ERCP are complimentary procedures in the diagnosis and therapy of pancreaticobiliary disorders. While both may be performed as a single tandem procedure (TP), there have been concerns about the safety of ERCP following EUSwith FNA, despite few data.We hypothesized that TP would allow multiple modalities to be combined in a single procedure without conferring additional risk. METHODS: 30-day outcomes of TP were evaluated prospectively with complications defined byERCP consensus criteria. RESULTS: 130 consecutive patients underwent TP, with EUS performed first in 120 (92%). Sedation was by GI (24) or anesthesia (MAC 9, general 97). Primary indication was diagnosis/staging/treatment of suspected pancreatic/biliary tumor (47), ampullary tumor (7), suspected CBD stone (7), suspected SOD (23), acute recurrent pancreatitis (22), chronic pancreatitis (5), pseudocyst drainage (15), and other (4). EUSmaneuvers included FNA in 39 patients (30%) [pancreas (30), liver (6), lymph node (3), CBD (2) and/or ampulla (2) and celiac neurolysis (6)]. ERCP maneuvers included SO manometry (27), sphincterotomy (67 biliary, 35 pancreatic), biliary stent (27 plastic, 19 metallic), and pancreatic stent (53 plastic, 1 metallic). Combined EUS/ERCP maneuvers included pseudocyst drainage (15) and EUS-guided rendezvous ERCP for duct drainage (4). Following TP, pancreatitis occurred in 12 (9.2%), none severe, and all but 1 after high-risk therapeutic ERCP (including SOD and recurrent pancreatitis); rates of pancreatitis were similar with (3/39) vs. without FNA (9/91)(p=0.75). Perforation occurred after 2 transmural pseudocyst drainages (1 operated), but none undergoing FNA. 40 (31%) patients were discharged on the day of the procedure; median hospital stay was 1 day. In the 33 possible tumor cases that had FNA, intraprocedural cytologic analysis showed malignancy in 22 (67%); tumor was staged as unresectable in 16/22 (73%), allowing for metallic stent placement (16) and celiac neurolysis (6). All CBD and main PD stones, and all but one pancreas divisum found by EUS were confirmed and treated at ERCP. CONCLUSIONS: Tandem EUS and ERCP is relatively safe with no complications specifically attributable to performance of FNA during EUS. Combining procedures allowed multiple modalities for diagnosis, staging and definitive therapy such metallic stenting, celiac neurolysis and pseudocyst drainage to be performed during a single procedure.