EUS-FNAKarolinska experiences

Karin von Sivers – Diagnostic RadiologyVitali Sviatoha – Pathology and Cytology

Edneia Tani – Pathology and CytologyKarolinska University Hospital - Solna

Stockholm - Sweden

Use of Endoscopic ultrasound guided FNA

• Difficult accessible intrathoracic, intraabdominal and gastrointestinal lesions.

• Aspiration biopsy during endoscopicprocedure.

• Alternative for open surgical, laparascopical biopsy.

Advantages of Endoscopic ultrasound guided FNA:

• Aspirates from difficult accessible lesions:- mediastinal lymph nodes / tumors, lung tumors.- esophageal wall- ventricular wall - gallbladder, liver - pancreas, spleen, left adrenal gland- intraabdominal cavity- colon

• Enough material for morphology and ancillary techniques.

• Less traumatic than surgical biopsy• Cheaper than surgical biopsy• Visible US structure of the lesion, adjacent

structures and vascularisation (Doppler).

Disadvantages of Endoscopicultrasound guided FNA:

• Experienced personal needed.• More expensive than usual FNA or US-

guided FNA.• Time consuming procedure comparing to

usual FNA or US-guided FNA.(ca 30 min at Karolinska Hospital).

EUS-FNABRetrospective study

337 patients2001-2007

174 male : 163 femaleAge: 2-86 year

• Supradiafragmatic 181• Infradiafragmatic 156

EUS-FNAB

• Outpatient examination• No coagulation status • Fasting 4 hours• Pharyngeal anestesia with spray• Sedation- Midazolam 1mg/ml, 2-5 mg i.v.

(Ketogan 2.5mg, 1mg/ml i.v.) • Time required aprox 30 min

Endoscopic video image

EUS- linear scanning

EUS - radial scanning

EUS-INTERVENTIONSector/Linear

Olympus GF-ULT 160

Power Doppler

EUS-FNAB

Olympus 0,7 mm 22GCook 0,5 mm 25GBiopsy channel 3.8mm

Smear

Cell suspension

Cytopathologist assistance on site

• Clinical information• Smear preparation• Cell suspension• Quick staining • Microscopy

EUS-FNAC

MGG, Papsmears Mib-1, TTF-1, CDX2

ER, PR, AR

cytospin (immuno, FISH)cell susp flow cytometry

gene rearrangement

cell block (coagulated material)

bacteriology

EUS-FNAC: 337 patients

immuno flow156 infradiafragmatic 51 1181 supradiafragmatic 86 8

____________137 (40%) 9

EU-FNA: 337 cases

CYTOLOGIC DIAGNOSIS:

Benign 151 (5 false negative)Malignant 153Suspicious 13Non diagnostic 20

False negative : 5 cases

• Mucinous cystic pancreas tumor- ca in situ• Pancreas cancer• Esofagus cancer recurrence• Sclerosing esofagus ca• Cardia cancer

Supradiafragmatic: 181 cases

• Mediastinal lymph nodes 145 • Esophagus 15 • Lung 12 • Pleura 3• Paravertebral lesion 3• Intrathoracal goiter 2• Paraesophageal 1

Infradiafragmatic: 156 cases

• Pancreas 92 • Stomach 27• Abdominal cavity 9• Lymph node 7 • Adrenal 6• Duodenum 3• Mesenterium 2• Spleen 1• Other retroperitoneal 8

Supradiafragmatic EUS-FNA: 181 cases

Malignant 84 casesBenign 85 casesSuspicious 9 casesNon diagnostic 3 cases

________________Total: 181 cases

Supradiafragmatic FNA: 181 cases(malignant: 84 cases)

Mediastinal nodes• 18 adeno ca• 14 poorly diff ca• 6 SCLCA• 6 squamous ca• 5 neuroendocrine ca• 2 melanoma• 2 renal cell ca• 1 prostate ca• 1 Merkel cell ca• 1 breast• 1 adrenal• 1 sarcoma

Lung • 5 adeno ca• 3 poorly diff ca• 2 SCLCA• 1 squamous ca• 3 metastasisPleura• 3 mesotheliomaEsophagus• 1 adeno caMediastinum• 1 sarcoma

TTF-1

CK7

CK20

adenocarcinoma

Small cell lungcancer

MGGiemsa cytokeratin

Supradiafragmatic FNA: 181 cases(Benign: 85 cases)

Benign diagnosis:• 29 benign lymph node• 24 granulomatous lymphadenitis• 2 granular cell tumor – esophagus• 2 intrathoracal goiter• 2 schwannoma

Recurrence paresis. Malignancy?

Infradiafragmatic EUS-FNA: 156 cases

Malignant 69 cases Benign 66 casesSuspicious 10 casesNon diagnostic 11 cases

________________Total: 156 cases

Infradiafragmatic EUS-FNA: 156 casesMalignant:69 cases Benign: 66 cases

Adenocarcinoma• 38 pancreas• 3 lymph node • 2 intra abdomnal• 1 gastricGIST • 9 gastricMetastasis• 5 adrenal (lung ca)• 2 pancreas• 1 spleen (melanoma

Neuroendocrine tumor• 3 pancreas• 3 gastricLymphoma• 3 lymph nodeSarcoma• 1 retroperitoneal

Benign cyst• 20 pancreas

GIST

CD117

CK

HMB45 S100

EU-FNA: 337 cases

Malignant 153Benign 151 Suspicious 13 (3.8%)Non diagnostic 20 (5.9%)

____________Total 337

EUS-FNAC: 337 cases

13 (3.8%)

20 (5.9%)

181156337total

3(4.9%)2 (3%)3031612007

4(3.5%)7 (6%)54601142006

3(4.8%)1 (1.6%)3527622005

2(3.5%)3 (5%)3027572004

1(3.4%)5 (17%)1910292003

-2 (16%)120122002

-01122001

suspnon diagsupradiafinfradiafnryear

Endoscopic ultrasound guided FNA

Conclusions:- Is a reliable diagnostic method for difficult

accessible intraabdominal and thoracic lesions.- Cooperation between endoscopist and

cytopatologist is important.- Correct care of the sample for morphology and

different ancillary techniques- On site assessment of sample with quick

staining and microscopy

Final message

For endoscopists: look for experiencedcytopathologists!

For cytopathologists: work in cooperationwith skillfull endoscopists!

Thank you for your attention !