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  • EndoscopicEndoscopic ultrasound ultrasound guidedguided FNA of FNA of

    suprasupra-- and and infradiaphragmaticinfradiaphragmatic lesions. lesions.

    Karolinska Karolinska experienceexperience -- cytologycytology highlightshighlights..

    VitaliVitali SviatohaSviatoha, , EdneiaEdneia TaniTani, Karin von , Karin von SiversSivers

    (Stockholm, Sweden)(Stockholm, Sweden)

  • Karolinska University HospitalKarolinska University Hospital

    Department of Clinical Department of Clinical CytologyCytology

    Department of Department of EndoscopyEndoscopy

  • UseUse of of EndoscopicEndoscopic ultrasound ultrasound guidedguided FNA FNA

    �� Difficult accessible Difficult accessible intrathoracicintrathoracic, ,

    intraabdominalintraabdominal and gastrointestinal and gastrointestinal

    lesions.lesions.

    �� Alternative for an open surgical, Alternative for an open surgical,

    laparascopicallaparascopical biopsy. biopsy.

  • AdvantagesAdvantages of of EndoscopicEndoscopic ultrasound ultrasound guidedguided FNA:FNA:

    �� Aspirates from difficult accessible lesions:Aspirates from difficult accessible lesions:

    -- mediastinalmediastinal lymphnodeslymphnodes, , tumourstumours..

    -- paraesophagealparaesophageal, , paraventricularparaventricular lesionslesions

    -- ventricular wallventricular wall

    -- gallbladder, liver gallbladder, liver

    -- pancreas, spleen, adrenal glandspancreas, spleen, adrenal glands

    -- intraabdominalintraabdominal cavitycavity

    -- coloncolon

    �� Plenty of material (due to the long needle).Plenty of material (due to the long needle).

    �� Less traumatic than surgical biopsyLess traumatic than surgical biopsy

    �� Cheaper than surgical biopsyCheaper than surgical biopsy

    �� Visible US structure of the lesion, adjacent Visible US structure of the lesion, adjacent structures and structures and vascularisationvascularisation (Doppler). (Doppler).

  • Disadvantages of Disadvantages of EndoscopicEndoscopic ultrasound ultrasound guided FNA:guided FNA:

    �� Experienced personal needed.Experienced personal needed.

    �� More expensive than usual FNA or USMore expensive than usual FNA or US--guided guided

    FNA.FNA.

    �� Time consuming procedure comparing to usual Time consuming procedure comparing to usual

    FNA or USFNA or US--guided FNA.guided FNA.

    (ca 30 min at Karolinska Hospital).(ca 30 min at Karolinska Hospital).

    �� Little cytological experience in some lesions.Little cytological experience in some lesions.

  • Prerequisites for successful Prerequisites for successful

    endoscopicendoscopic FNA. FNA.

    �� Close cooperation between radiologist and cytologist!Close cooperation between radiologist and cytologist!

    �� Assessment of the aspirated material Assessment of the aspirated material ““on placeon place””

    -- quick stain with microscopy. quick stain with microscopy.

    �� Management of the aspirated material:Management of the aspirated material: -- morphology morphology

    -- immunoassaying immunoassaying

    -- additional analyses (microbiology, molecular analysis) additional analyses (microbiology, molecular analysis)

    �� Good smearing technique.Good smearing technique.

    �� Several aspirations.Several aspirations.

  • Karolinska Hospital experience in Karolinska Hospital experience in endoscopicendoscopic ultrasound ultrasound guidedguided FNAFNA

    �� Started at 2001Started at 2001

    �� 337 patients so far: 337 patients so far: SupradiafragmaticSupradiafragmatic-- 181181

    SubdiafragmaticSubdiafragmatic -- 156156

    �� 174 males and 163 females. Age range:174 males and 163 females. Age range:

    SupradiafragmaticSupradiafragmatic: 27: 27--89, median 65 89, median 65

    SubdiafragmaticSubdiafragmatic: 2: 2--85, median 64,5 85, median 64,5

  • SupradiafragmaticSupradiafragmatic organs: 181 organs: 181 casescases

    �� MediastinalMediastinal lymphlymph nodesnodes 145 145 casescases

    �� EsophagusEsophagus 15 15 casescases

    �� LungLung 12 12 casescases

    �� PleuraPleura 33

    �� ParavertebralParavertebral lesionlesion 33

    �� IntrathoracalIntrathoracal goitergoiter 22

    �� ParaesophagealParaesophageal 11

  • InfradiafragmaticInfradiafragmatic organs: 156 organs: 156 casescases

    �� PancreasPancreas 92 92 casescases

    �� StomachStomach 2727

    �� Abdominal Abdominal cavitycavity 99

    �� LymphLymph nodenode 7 7

    �� AdrenalAdrenal 66

    �� DuodenumDuodenum 33

    �� MesenteriumMesenterium 22

    �� SpleenSpleen 11

    �� OtherOther retroperitonealretroperitoneal 88

  • CYTOLOGICAL DIAGNOSISCYTOLOGICAL DIAGNOSIS

    BenignBenign 151 (5 151 (5 falsefalse negative)negative)

    MalignantMalignant 153153

    SuspiciousSuspicious 1313

    Non Non diagnosticdiagnostic 2020

  • SupradiafragmaticSupradiafragmatic FNA: 181 FNA: 181 casescases

    MediastinalMediastinal nodesnodes

    �� 18 18 adenoadeno caca

    �� 14 14 poorlypoorly diffdiff caca

    �� 6 SCLCA6 SCLCA

    �� 6 squamous ca6 squamous ca

    �� 5 5 neuroendocrineneuroendocrine caca

    �� 2 2 melanomamelanoma

    �� 2 2 renalrenal cell cacell ca

    �� 1 1 prostateprostate caca

    �� 1 1 MerkelMerkel cell cacell ca

    �� 1 1 breastbreast

    �� 1 1 adrenaladrenal

    �� 1 1 sarcomasarcoma

    LungLung

    �� 5 5 adenoadeno caca

    �� 3 3 poorlypoorly diffdiff caca

    �� 2 SCLCA2 SCLCA

    �� 1 squamous ca1 squamous ca

    �� 3 3 metastasismetastasis

    PleuraPleura

    �� 3 3 mesotheliomamesothelioma

    EsophagusEsophagus

    �� 1 1 adenoadeno caca

    MediastinumMediastinum

    �� 1 1 sarcomasarcoma

  • InfradiafragmaticInfradiafragmatic EUSEUS--FNA: 156 FNA: 156 casescases

    AdenocarcinomaAdenocarcinoma

    �� 38 38 pancreaspancreas

    �� 3 3 lymphlymph nodenode

    �� 2 2 intraintra abdomnalabdomnal

    �� 1 1 gastricgastric

    GIST GIST

    �� 9 9 gastricgastric

    MetastasisMetastasis

    �� 5 5 adrenaladrenal

    �� 2 2 pancreaspancreas

    �� 1 spleen1 spleen

    NeuroendocrineNeuroendocrine tumortumor

    �� 3 3 pancreaspancreas

    �� 3 3 gastricgastric

    LymphomaLymphoma

    �� 3 3 lymphlymph nodenode

    SarcomaSarcoma

    �� 1 1 retroperitonealretroperitoneal

    Benign Benign cystcyst

    �� 20 20 pancreaspancreas

  • CytologicalCytological EquipmentEquipment -- Needles: Needles: OlympusOlympus 0,7 mm 22G 0,7 mm 22G

    Cook 0,5 mm, 25GCook 0,5 mm, 25G

    -- CytologicalCytological slides for slides for smearssmears and and immunostainingsimmunostainings..

    -- Solution for cell suspension (PBS).Solution for cell suspension (PBS).

    -- Formalin solution for cellblocksFormalin solution for cellblocks

    -- Vials for bacteriological analysisVials for bacteriological analysis

  • SmearingSmearing techniguetechnigue

  • SmearingSmearing techniguetechnigue

  • ImmunostainingImmunostaining �� Cellsuspension: Cellsuspension: airair--dryeddryed

    slides, aceton slides, aceton fixationfixation, ,

    alkalinealkaline phosphatasephosphatase methodmethod..

    �� CytologicalCytological smearssmears: : formalinformalin--

    fixedfixed slides, slides, storagestorage medium, medium,

    peroxidaseperoxidase methodmethod

    �� Cellblock: Cellblock: formalinformalin--fixedfixed

    matherialmatherial, , histologicalhistological

    proceedingproceeding, , peroxidaseperoxidase

    methodmethod..

  • ImmunostainingImmunostaining �� CellsuspensionCellsuspension: :

    �� CytologicalCytological smearssmears: :

    formalinformalin--fixedfixed slides, slides,

    storagestorage medium, medium,

    peroxidaseperoxidase methodmethod

  • Karolinska Hospital experience in Karolinska Hospital experience in endoscopicendoscopic ultrasound ultrasound guidedguided FNAFNA

    �� IntraabdominalIntraabdominal lesions: Metastatic lesions: Metastatic mucinousAdenocarcinomamucinousAdenocarcinoma of the ovaryof the ovary

  • Karolinska Hospital experience in Karolinska Hospital experience in endoscopicendoscopic ultrasound ultrasound guidedguided FNAFNA

    �� IntraabdominalIntraabdominal lesions: Metastatic mucinous adenocarcinoma of the ovarylesions: Metastatic mucinous adenocarcinoma of the ovary

  • Karolinska Hospital experience in Karolinska Hospital experience in endoscopicendoscopic ultrasound ultrasound guidedguided FNAFNA

    �� IntraabdominalIntraabdominal lesions: Metastatic serous papillary cancer of the ovarylesions: Metastatic serous papillary cancer of the ovary

  • Karolinska Hospital experience in Karolinska Hospital experience in endoscopicendoscopic ultrasound ultrasound guidedguided FNAFNA

    �� IntraabdominalIntraabdominal lesions: Metastatic serous papillary cancer of the ovarylesions