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

More documents

Recommendations

Info

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-
1978 DeWitt et al. AJG – Vol. 98, No. 9, 2003 Table 2. Characteristics of EUS Examination All* (n 77) Malignant† (n 48) Benign‡ (n 22) p-value§ Site of FNA Left lobe 66 (86) 41 (85) 20 (91) 0.57 Right lobe 11 (14) 7 (15) 2 (9) No. of passes 3.4 1.8 3.5 1.5 3.2 1.5 0.44 Range 1–8 1–8 1–8 Echogenicity Hypoechoic 52 (68) 33 (69) 13 (59) 0.36 Hyperechoic 23 (30) 13 (27) 9 (41) Both 2 (2) 2 (4) 0 (0) Margins Regular 39 (51) 29 (60) 6 (27) 0.02 Irregular 38 (49) 19 (40) 16 (73) Size (mm) 16.0 10.8 15.6 7.7 16.7 12.0 0.70 Range 3–40 3–35 4–40 No. of lesions seen 1 57 (74) 30 (62) 20 (91) 0.03 1 20 (26) 18 (38) 2 (9) * Includes seven patients unable to be classified as benign or malignant. † Includes 45 positive and three false negative EUS-FNA results. ‡ By follow-up or intraoperative findings. § Between malignant and benign lesions. cations (upper 95% CI 4.7%; see Table 2). A total of 45 (58%) aspirates were diagnostic for malignancy. Three false negatives were later discovered by intraoperative findings (n 2) or P-FNA (n 1). One patient with pancreatic adenocarcinoma (as confirmed by EUS-FNA of the pancreas) had benign cytology of a 6-mm left lobe mass that intraoperatively was confirmed as metastatic adenocarcinoma. A second patient with pancreatic adenocarcinoma (as confirmed by EUS-FNA of the pancreas) had benign cytology of a 6-mm right lobe mass, which was later confirmed by percutaneous ultrasound-guided biopsy as metastatic adenocarcinoma. The third patient with a false negative EUS-FNA had a 29-mm left lobe mass that was benign by EUS-FNA. Intraoperative examination, however, confirmed hepatocellular carcinoma. Overall, 48 of 77 (62%) of the liver masses were malignant. Among the remaining 29 subjects with nonmalignant aspirates, in 22 (76%) the masses were considered benign by clinical follow-up (n 18; mean 762 days; range: 512–1556 days) or intraoperative evaluation (n 4). Seven (24%) of the subjects with nonmalignant masses with pancreatic adenocarcinoma (as confirmed by EUS-FNA of the pancreas; n 6) or lung cancer (n 1) died (mean 154 days, range 14–424 days) without follow-up imaging, biopsy of the liver, or autopsy and therefore cannot be classified as benign or malignant. The 45 diagnostic aspirates for malignancy are considered true positives (Fig. 1). Assuming that the test results for these seven patients were all true negatives or all false negatives, the sensitivity of EUS-FNA for the diagnosis of malignancy would range from 82 to 94%. In comparison between benign and malignant lesions detected by EUS-FNA (Table 2), no statistically significant difference was found between the liver lobe aspirated (p 0.57), number of passes (p 0.44), lesion size (p 0.70), Figure 1. Sensitivity of EUS-FNA of the liver for the diagnosis of malignancy. or echotexture (p 0.36). Malignant masses, however, were more often accompanied by the presence of multiple hepatic lesions detected on EUS (38% vs 9%; p 0.03; 2 analysis) and to have regular margins (60% vs 27%; p 0.02; 2 analysis). Diagnoses from EUS-FNA of the Liver The final diagnoses for the 45 malignant liver aspirates are recorded in Table 3. Of these, 44 (98%) were metastatic and one (2%) was a hepatocellular carcinoma. The most common diagnosis was metastatic adenocarcinoma from the pancreas, which accounted for 34 of 45 (76%). The next most frequent diagnosis was metastatic neuroendocrine tumor from the pancreas (n 5; 11%). Of the 32 nonmalignant aspirates, 25 (33%) were cytologically benign and seven (9%) were nondiagnostic. One (4%) benign aspirate demonstrated cytological features consistent with an abscess. Previous Imaging of Malignancy Diagnosed by EUS-FNA Prior radiographic imaging reports were available for 42 of 45 (93%) malignant hepatic masses diagnosed by EUS- Table 3. Diagnoses of Malignant Aspirates of the Liver Diagnosis No. (%) Pancreatic adenocarcinoma 34 (76) Pancreatic neuroendocrine tumor 5 (11) Renal cell carcinoma 2 (5) Gallbladder adenocarcinoma 1 (2) Colon cancer 1 (2) Hepatocellular carcinoma 1 (2) Esophageal adenocarcinoma 1 (2) Total 45
Page 1: THE AMERICAN JOURNAL OF GASTROENTER
Page 5 and 6: 1980 DeWitt et al. AJG - Vol. 98, N

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?