endoscopic ultrasound guided fna of supra - and...
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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: Metastatic serous papillary cancer of the ovary
PsammomaPsammoma bodies Estrogen receptobodies Estrogen receptorsrs
Karolinska Hospital experience in Karolinska Hospital experience in endoscopicendoscopic ultrasound ultrasound guidedguided FNAFNA
�� 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
Karolinska Hospital experience in Karolinska Hospital experience in endoscopicendoscopic ultrasound ultrasound guidedguided FNAFNA
�� IntraabdominalIntraabdominal lesions: Adenoma of papilla lesions: Adenoma of papilla VateriVateri
Karolinska Hospital experience in Karolinska Hospital experience in endoscopicendoscopic ultrasound ultrasound guidedguided FNAFNA
�� IntraabdominalIntraabdominal lesions: Metastatic colon adenocarcinomalesions: Metastatic colon adenocarcinoma
Karolinska Hospital experience in Karolinska Hospital experience in endoscopicendoscopic ultrasound ultrasound guidedguided FNAFNA
�� IfradiafragmalIfradiafragmal lesions: lesions: PseudapapillaryPseudapapillary pancreatic cancerpancreatic cancer
α1AT
Karolinska Hospital experience in Karolinska Hospital experience in endoscopicendoscopic ultrasound ultrasound guidedguided FNAFNA
�� IfradiafragmalIfradiafragmal lesions: lesions: PseudapapillaryPseudapapillary pancreatic cancerpancreatic cancer
α1AT
Karolinska Hospital experience in Karolinska Hospital experience in endoscopicendoscopic ultrasound ultrasound guidedguided FNAFNA
�� SupradiafragmalSupradiafragmal lesions: lesions: MesotheliomMesotheliom
Karolinska Hospital experience in Karolinska Hospital experience in endoscopicendoscopic ultrasound ultrasound guidedguided FNAFNA
�� SupradiafragmalSupradiafragmal lesions: SCLC lesions: SCLC
SYP
Karolinska Hospital experience in Karolinska Hospital experience in endoscopicendoscopic ultrasound ultrasound guidedguided FNAFNA
�� SupradiafragmalSupradiafragmal lesions: lesions: GranulomatousGranulomatous lesions/lesions/tbctbc..
Karolinska Hospital experience in Karolinska Hospital experience in endoscopicendoscopic ultrasound ultrasound guidedguided FNAFNA
�� 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!!!