Diagnostic bedside EUS in the intensive care unit: a single-center experience.

BACKGROUND: The knowledge of bedside diagnostic EUS in critically ill patients is limited. OBJECTIVE: To investigate the indications, feasibility, safety, and clinical utility of diagnostic EUS in the intensive care unit (ICU). DESIGN: Retrospective. SETTING: Tertiary-care referral teaching hospital. PATIENTS: All consecutive patients who had EUS done in the ICU within a 6-year period. INTERVENTION: Bedside EUS and EUS-guided FNA. MAIN OUTCOME MEASUREMENTS: EUS indications, complications, and impact on management. RESULTS: A total of 64 EUS procedures were performed in 63 patients (38 men, 25 women; age range 27-78 years); 1 patient underwent 2 separate EUS procedures. EUS was performed while the patients were mechanically ventilated in 70% (45/64) of cases. Indications for EUS included jaundice (n = 24), mass of unknown etiology (n = 25), unexplained pancreatitis (n = 7), and staging of known cancer (n = 3). In 5 cases, EUS was used as an alternative to other imaging modalities because of morbid obesity (n = 3) or contraindication to intravenous contrast material (n = 2). Complications included reversible oxygen desaturation (n = 4), nonsustained ventricular tachycardia (n = 1), and transient hypotension (n = 1). Overall, EUS influenced management in 97% (62/64) of cases. LIMITATIONS: Retrospective, single-center study. CONCLUSION: ICU-based EUS can be performed with few intraprocedural complications and can be a valuable diagnostic modality in the ICU setting. It appears to be particularly useful for determining the etiology of jaundice, masses of unknown etiology, and pancreatitis. It may have particular value as a diagnostic technique on selected patients with unstaged cancer and when morbid obesity or the inability to use intravenous contrast material precludes the use of other imaging modalities in the critically ill patient.

A limited immunocytochemical panel for the distinction of subepithelial gastrointestinal mesenchymal neoplasms sampled by endoscopic ultrasound-guided fine-needle aspiration.

We studied the use of immunocytochemical analysis with material procured by endoscopic ultrasound-guided fine-needle aspiration (EUS-guided FNA) for the diagnosis of subepithelial intramural gastrointestinal (GI) mesenchymal neoplasms (SIGIMNs). We identified all EUS-guided FNA specimens of SIGIMNs that had undergone immunocytochemical analysis. Results were compared with follow-up histologic diagnoses. There were 95 aspirates that were diagnosed as GI mesenchymal tumors (GI stromal tumors [GISTs], n = 46), leiomyomas (n = 38), peripheral nerve sheath tumors (n = 5), and other neoplasms by cytologic examination. Immunoreactivity with antibodies to CD117 always predicted GIST at follow-up; 15 of 16 cases immunoreactive with antibodies to CD34 were found to be GISTs at follow-up. Strong immunoreactivity with antibodies to smooth muscle actin or desmin usually predicted a leiomyoma at follow-up aside from a single glomus tumor and a case with apparent nonneoplastic smooth muscle contaminant. When sufficient material is present, immunocytochemical analysis used with material obtained by EUS-guided FNA is highly predictive of final pathologic diagnosis.

The use of fine needle aspiration cytology for the distinction of pancreatic mucinous neoplasia.

Cytology frequently has some role in preoperatively distinguishing pancreatic mucus-producing neoplasia (intraductal papillary mucinous neoplasms [IPMNs] and mucinous cystic neoplasms [MCNs]) from other pancreatic cysts. We evaluated all cytologic specimens at our institutions from resected pancreatic cystic lesions for lesional extracellular and cellular material. Lesional extracellular material was identified in 32 of 38 of the cytologic samples from cystic pancreatic mucus-producing neoplasms (28 of 31 IPMNs and 4 of 7 MCNs). Lesional cellular material was seen in 22 of 38 cases (17 of 31 IPMNs and 5 of 7 MCNs). Lesional material was more commonly identified in higher grade and invasive lesions. Lesional extracellular material was seen in 3 of 14 samples of other pancreatic cysts, and lesional cellular material was seen in 6 of 14 cases.

Sampling of the adrenal glands by endoscopic ultrasound-guided fine-needle aspiration.

Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) has proven to be a valuable modality for the primary diagnosis and staging of gastrointestinal, and perigastrointestinal malignancy. Aside from assessing thoracic and abdominal lymph nodes and the liver for metastases, EUS can assess and sample the adrenal glands, which are frequently involved by metastatic disease, but can also harbor benign primary neoplasms. The cytology files at our institution were reviewed for all cases of EUS-guided FNA of the adrenal glands. Clinical histories, sonographic findings, and cytologic findings of all cases were reviewed. Results were compared with overall EUS-guided FNA performance and the performance of non-EUS-guided FNA of the adrenal. The utility of cell block immunohistochemistry (IHC) in these cases was reviewed. Between 1/1/00 and 5/15/04 there were 24 cases of EUS-guided FNA of the adrenal gland from 22 different patients (13 men; 9 women) at our institution. This represented 1.4% of overall EUS-guided FNA and 77% of adrenal gland FNA. Patient ages ranged from 37 to 86 yr (mean 69 +/- 11 yr). Most patients had other cancers or mass lesions and were being staged at the time of the procedure (19 of 22). Almost all FNAs were of the left adrenal gland (23 of 24). Lesion size ranged from 0.9 to 7.9 cm (mean 2.5 +/- 1.6 cm). Diagnostic material was present in all cases when compared with an overall EUS-guided FNA diagnostic rate of 88%. Material for cell block was present in 21 cases, and IHC was used in 3 cases. Final diagnoses were as follows: cortical tissue consistent with cortical adenoma (19), metastatic adenocarcinoma (3), pheochromocytoma (1), and adrenal cortical carcinoma (1). EUS-guided FNA of the adrenal gland is primarily used in the staging of other malignancies when lesions of the left adrenal are recognized sonographically. Diagnostic tissue is easily obtained, including material for cell block IHC, which allows definitive diagnosis in cases that present difficult differential diagnoses.

The cytology of pancreatic foamy gland adenocarcinoma.

All cell block specimens from pancreatic fine-needle aspirations (FNAs) obtained between January 1, 2002, and June 30, 2003, were reviewed for foamy gland adenocarcinoma (FGA). All smears from these cases were reviewed for cytologic features, including those previously noted in conventional pancreatic adenocarcinoma. Fifty-two cell block specimens showed adenocarcinoma. Of these, 12 (23%) showed histologic features of FGA. This pattern predominated in 6 cases and was present focally in 6 cases. Although there were relatively low nuclear/cytoplasmic (N/C) ratios, other features of adenocarcinoma were present universally, including loss of cohesiveness, nuclear overlap or loss of "honeycomb" architecture, anisonucleosis (> 4 to 1), irregular nuclear contours, prominent nucleoli, and atypical chromatin. Background necrosis was present in 8 cases. Distinct cell borders were present in 9 cases, and foamy cytoplasm was present in all cases. Pancreatic FGA is a recently described histologic pattern of pancreatic adenocarcinoma. It is not uncommon, and we identified the pattern, at least focally, in 23% of our FNA cell blocks. Although cytologic samples show low N/C ratios, most cytologic features of conventional pancreatic adenocarcinoma are present, and the diagnosis presents little additional difficulty.

Glomus tumor of the stomach: cytologic diagnosis by endoscopic ultrasound-guided fine-needle aspiration.

The glomus tumor is usually a benign solitary neoplasm that arises from modified smooth muscle cells of the glomus body, a type of neuromyoarterial receptor that plays a role in the regulation of arterial blood flow. We report a case of gastric glomus tumor diagnosed by endoscopic ultrasound-guided fine-needle aspiration. Smears exhibited groups of cohesive, uniform, small, round to polygonal cells with scant cytoplasm, indistinct cell borders, and round, hyperchromatic nuclei with homogeneous chromatin. The cell block contained fragments of cells with similar morphologic features and immunohistochemical staining exhibited positivity for smooth muscle actin and vimentin. The diagnosis was confirmed by the surgically resected specimen. Ultrastructural examination revealed prominent pinocytotic vesicles lining the plasmalemma. In this report, we discuss the differential diagnosis of gastric glomus tumor and compare the cytologic features of this case with two others reported in the literature.

Transfusion-related acute lung injury during plasma exchange: Suspecting the unsuspected.

Transfusion-related acute lung injury (TRALI) has been implicated with use of almost all types of blood products that contain variable amounts of plasma. Even though the reported incidence of TRALI is rare, its overall occurrence is thought to be more common, as less severe cases remain unreported. More TRALI cases are unrecognized and misdiagnosed due to lack of suspicion and absence of appropriate investigation. There are exceedingly rare reports of TRALI during plasma exchange despite the fact that liters of plasma may be used for replacement during a single procedure. We describe a mild case of TRALI during plasma exchange for thrombotic thrombocytopenic purpura in a 56-year-old woman, status post autologous hematopoietic stem cell transplant for non-Hodgkin's lymphoma. She developed severe rigors, peripheral cyanosis, hypoxia, and a transient diffuse pulmonary infiltrate. Of the 10 U of plasma used, one was from a multiparous female donor with HLA antibodies reactive with patient's granulocytes in immunofluorescence and agglutination assays. This case emphasizes the fact that the physicians and apheresis staff should consider TRALI in the differential diagnosis for patients developing respiratory distress during or soon after the procedure. Diagnosing TRALI has implications not only for the plasma exchange recipient, but also for the management of donors found to have leukocyte antibodies.