Endoscopic Ultrasound–Guided Fine Needle Aspiration Cytology of ...

AJG – September, 2003
EUS-FNA Cytology of Solid Liver Lesions
1977
Table 1. Indications for EUS Examinations by Cytology Results of
EUS-FNA of the Liver
Melville NY). The right lobe of the liver was surveyed from
the duodenum and distal stomach, whereas the left lobe was
imaged from the proximal and mid-stomach. Endoscope
rotation was used as necessary to visualize as much of the
liver parenchyma as possible. EUS-FNA was performed
using the Pentax 32-UA, Pentax 36-UX (Pentax Precision
Instruments, Orangeburg, NY), Olympus GF-UC30P, or
Olympus GF-UC140P curvilinear array echoendoscope.
EUS-FNA was performed using a 22-gauge, 8-cm Wilson-
Cook EUSN-1, EUSN-2, or EUSN-3 needle (Wilson-Cook
Medical, Winston-Salem, NC) by one of four physicians
(J.D., D.C., L.M., or J.L.). Doppler color angiography was
used to ensure the absence of intervening vascular structures
along the anticipated needle path. Depending on the amount
of blood anticipated during tissue sampling, full, partial, or
no suction was applied at the discretion of the endoscopist,
cytotechnologist, or cytopathologist. A cytotechnologist or
cytopathologist was available on-site for preliminary interpretations
on all procedures. Samples aspirated were expressed
onto a glass slide and two smear preparations were
made. One slide was air-dried and stained with a modified
Giemsa stain for rapid on-site interpretation. The other slide
was alcohol-fixed and stained by the Papanicolaou method.
EUS-FNA was repeated until a definitive diagnosis was
made or the endoscopist believed that further sampling
would not likely increase yield. Within several days of each
EUS examination, a final cytological diagnosis was rendered
by a staff cytopathologist.
A true positive EUS-FNA for malignancy is defined as
unequivocal cytological evidence of malignancy. A false
negative aspirate is a nondiagnostic or benign specimen,
which is subsequently found to be malignant by percutaneous
FNA or intraoperative findings. A true negative EUS-
FNA for malignancy is defined as benign or nondiagnostic
samples that are either confirmed as benign by alternative
sampling, intraoperative examination, or appropriate clinical
follow-up. Specimens with benign hepatocytes without
evidence of atypical cells are categorized as benign aspirates.
Aspirates from EUS-FNA that are interpreted as nondiagnostic,
highly suspicious, suspicious, or atypical for
malignancy are considered as negative for malignancy.
Medical records of enrolled subjects were reviewed and
procedural indications, prior radiographic data, patient demographics,
EUS test results, clinical outcomes, procedural
complications, and follow-up data were abstracted. When
multiple liver lesions were noted, the endosonographic description
of only the aspirated lesion was recorded. When
charts were incomplete, written informed consent was sent
and follow-up telephone calls were made to the subject,
closest relative of the deceased, or referring physician for
clarification or any required further information. The potential
clinical impact of EUS-FNA of a liver metastasis or
malignancy is defined as results that met the following
criteria: 1) avoided surgery (results precluded resectable
malignancy); 2) made diagnosis (results provided initial
diagnosis of malignancy); 3) upstaged tumor (results upstaged
primary malignancy); 4) incurred no change in management
(results did not change patient treatment). This
study was approved by the Institutional Review Board at our
institution.
Statistical Analysis
Assuming that the EUS-FNA diagnosis of malignancy is a
true positive, sensitivity was calculated as the proportion of
patients with cancer in whom EUS-FNA was positive for
malignancy. For analysis, continuous variables were described
as means and standard deviations, and dichotomous
variables were expressed as simple proportions with or
without 95% confidence limits. Student’s t test and 2 or
Fisher’s exact tests were used to test for differences in
comparisons between continuous and dichotomous variables,
respectively.
RESULTS
Indication
All
(n 77)
Cytology Result
Malignant
(n 45)
Benign/ND
(n 32)
Abnormal ERCP 21 (27) 11 (24) 10 (31)
Pancreatic mass on CT 19 (25) 12 (27) 7 (22)
Staging of known cancer 10 (13) 7 (16) 3 (9)
Liver mass on CT 9 (12) 9 (20) 0 (0)
Other abnormal CT findings 4 (5) 1 (2) 3 (9)
Suspected recurrent cancer 2 (3) 1 (2) 1 (3)
Chronic abdominal pain 2 (3) 0 (0) 2 (7)
Other 10 (12) 4 (9) 6 (19)
Total 77 45 32
ND nondiagnostic
In total, EUS-FNA was performed on 77 different liver
lesions in 77 patients (42 male and 35 female, 69 white and
eight African American, with a mean age of 63 11 yr).
Follow-up was available in all patients.
Indications for EUS Examinations
The indications for the 77 EUS procedures are recorded in
Table 1. The two most common indications were abnormal
ERCP findings, the majority of which were strictures, and a
pancreatic mass on CT scan, which accounted for 27% and
25% of the procedures performed, respectively. Ten (13%)
of 77 procedures were done for staging of a recently diagnosed
malignancy (pancreas in five, esophageal in four, and
lung in one). Of the 45 malignancies diagnosed by EUS-
FNA, the most common indications for the EUS were a CT
finding of a pancreatic mass (27%) and abnormal ERCP
findings (24%).
Characteristics of EUS Examination
EUS-FNA was performed in 77 patients (mean 3.4 1.8
passes, range 1–8) into the left lobe (n 66; 86%) and right
lobe (n 11; 14%) of the liver without procedural compli-