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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


�� 3 3 poorlypoorly diffdiff caca

�� 2 SCLCA2 SCLCA

�� 1 squamous ca1 squamous ca

�� 3 3 metastasismetastasis

PleuraPleura

�� 3 3 mesotheliomamesothelioma

EsophagusEsophagus


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


MetastasisMetastasis

�� 5 5 adrenaladrenal


�� 1 spleen1 spleen

NeuroendocrineNeuroendocrine tumortumor



LymphomaLymphoma

�� 3 3 lymphlymph nodenode

SarcomaSarcoma

�� 1 1 retroperitonealretroperitoneal

Benign Benign cystcyst


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

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


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


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


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


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

PsammomaPsammoma bodies Estrogen receptobodies Estrogen receptorsrs


�� IntraabdominalIntraabdominal lesions: Metastatic Endometrial lesions: Metastatic Endometrial StromalStromal SarcomaSarcoma

Karolinska Hospital experience in Karolinska Hospital experience in endoscopicendoscopic ultrasound ultrasound guidedguided FNAFNA�� IntraabdominalIntraabdominal lesions: GIST, cytologylesions: GIST, cytology

Karolinska Hospital experience in Karolinska Hospital experience in endoscopicendoscopic ultrasound ultrasound guidedguided FNAFNA�� IntraabdominalIntraabdominal lesions: variants of lesions: variants of carcinoidcarcinoid

SYP

CHROMO


�� IntraabdominalIntraabdominal lesions: Adenoma of papilla lesions: Adenoma of papilla VateriVateri


�� IntraabdominalIntraabdominal lesions: Metastatic colon adenocarcinomalesions: Metastatic colon adenocarcinoma


�� IfradiafragmalIfradiafragmal lesions: lesions: PseudapapillaryPseudapapillary pancreatic cancerpancreatic cancer

α1AT


�� SupradiafragmalSupradiafragmal lesions: lesions: MesotheliomMesotheliom


�� SupradiafragmalSupradiafragmal lesions: SCLC lesions: SCLC

SYP


�� SupradiafragmalSupradiafragmal lesions: lesions: GranulomatousGranulomatous lesions/lesions/tbctbc..


�� Reasons for nonReasons for non--diagnostic samples:diagnostic samples:

-- ““sendsend--inin”” material, poor smears.material, poor smears.

-- missinterpretationmissinterpretation during quick stain and/or during quick stain and/or macroevaluationmacroevaluation of the aspirate.of the aspirate.

-- ““missplacedmissplaced”” needle in the lesion (necrosis, poor needle in the lesion (necrosis, poor cellularitycellularity))

UseUse of of EndoscopicEndoscopic ultrasound ultrasound guidedguided FNAFNA

�� Highlights:Highlights:

-- A reliable diagnostic method for difficult A reliable diagnostic method for difficult

accessible accessible intraabdominalintraabdominal (thoracic) lesions.(thoracic) lesions.

-- Cooperation between radiologist and cytologist Cooperation between radiologist and cytologist

is of highest is of highest importancyimportancy..

Thank You!!!Thank You!!!