Comparison of endoscopic ultrasound-guided fine-needle aspiration by capillary action, suction, and no suction methods: a randomized blinded study.

BACKGROUND AND STUDY AIM: Different types of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) techniques are used in clinical practice; the best method in terms of outcome has not been determined. The aim of the study was to compare the diagnostic adequacy of aspirated material, and the cytopathological and EUS morphological features between capillary action, suction, and no-suction FNA methods. PATIENTS AND METHODS: This was a prospective, single-blinded, randomized study conducted at a tertiary care hospital. Patients were randomized to the three groups: capillary action, suction, and no suction. A total of 300 patients were included, with 100 patients in each arm. RESULTS: A total of 300 patients (195 males) underwent EUS-FNA of 235 lymph nodes and 65 pancreatic masses (distribution not statistically different between the groups). The mean age was 52 ±â€Š14 years. A 22 gauge needle was used in the majority (93 %) of procedures. There was no statistical difference between the three groups regarding lymph node size at the largest axis and ratio, type of needle, echo features, echogenicity, calcification, necrosis, shape, borders (lymph nodes), number of passes, and cellularity. Diagnostic adequacy of the specimen was 91 %, 91 %, and 94 % in the capillary, suction, and no suction groups, respectively ( P  = 0.67). Significantly more slides and blood clots were generated by the suction method compared with the other methods. CONCLUSION: The capillary action, suction, and no suction methods of EUS-FNA are similar in terms of diagnostic adequacy of the specimen. The suction method has the disadvantages of causing more bleeding and generating more slides.

Yield of endoscopic ultrasound-guided fine needle aspiration for subcentimetric lymph nodes: A comparison to larger nodes.

BACKGROUND AND OBJECTIVES: Subcentimetric (defined as <1 cm at short axis) lymph nodes are considered benign and there is limited literature on the results of fine needle aspiration (FNA) of these nodes. METHODS: Endoscopic ultrasound (EUS) guided FNA was done on 189 lymph nodes in 166 patients with pyrexia of unknown origin (n = 113) or malignancy (n = 53). Subcentimetric lymph nodes (Group A) were compared to nodes with short axis diameter ≥1 cm (Group B). Data are shown as number, percentage, and median (25-75 interquartile range). RESULTS: There was no significant difference between Group A and Group B regarding site of lymph nodes (mediastinal in 73.6 and 72.5%, abdominal in 26.3 vs. 27.4%), number of slides (median 14 vs. 15), needle passes (median 2), and needle used (22 G needle in 85.5% vs. 69.9%). Group A had significantly lesser long axis diameter (1.5 [1.2-2] vs. 2.1 [1.6-2.9] cm) and short axis diameter (0.7 [0.6-0.8) vs. 1.4 [1.1-1.6] cm). A diagnosis (pathologic or reactive) could not be made in 2 (2.6%) and 11 (9.7%) lymph nodes in Group A and Group B, respectively (P = 0.078), due to inadequate material. Respective diagnoses in Group A and Group B were reactive lymphadenopathy (51.3% vs. 18.5%, P = 0.000), granulomatous lymphadenopathy (34.2% vs. 53%, P = 0.011), and malignancy (11.8% vs. 18.5%, P = 0.231). The lymph nodes with granulomatous and malignant change were significantly larger and had higher chances of having sharply demarcated borders as compared to reactive nodes. CONCLUSION: EUS-guided FNA of subcentimetric lymph nodes have comparable results to larger nodes. Almost half of the subcentimetric lymph nodes are pathologic.

Isolated splenic tuberculosis diagnosed by endoscopic ultrasound-guided fine needle aspiration.

Our patient was a 48-year-old female, who presented with history of persistent low-grade fever and weight loss. The CT scan of the abdomen revealed multiple hypodense lesions in spleen. No primary focus of infection was detected in any other organs. Endoscopic ultrasound-guided fine needle aspiration of splenic lesion revealed granulomatous inflammation. The patient was started on anti-tuberculous therapy. There is a diagnostic possibility of splenic tuberculosis even in immunocompetent individuals and we chose a combination anti-tuberculous therapy as the first line treatment with consideration of splenectomy depending on the response.

Impact of endoscopic ultrasound-guided fine-needle aspiration in prospective liver transplant recipients with hepatocellular carcinoma and lymphadenopathy.

BACKGROUND: Diagnosis of metastatic disease is important in patients with cirrhosis and hepatocellular carcinoma (HCC) to prevent futile liver transplantation. Some of these patients have metastatic lymphadenopathy; however, it is difficult to perform percutaneous fine-needle aspiration due to presence of collateral and anatomic location. Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) of lymph nodes offers several advantages like real-time vision, proximity to target, and avoidance of collaterals. AIM: The aim of this study was to look for metastatic lymphadenopathy by EUS-guided FNA (EUS-FNA) in prospective liver transplant recipients with HCC. METHODS: A prospective study was conducted from January 2013 to January 2016 at a tertiary care center. All prospective liver transplant recipients with HCC had PET-CT and bone scan to look for metastatic disease. EUS-FNA was done in patients with abdominal or mediastinal lymphadenopathy and no evidence of extrahepatic disease. Data is shown as median (25-75 interquartile range). RESULTS: EUS-guided FNA was done for 50 patients (42 abdominal and 8 mediastinal lymph nodes), age 57 (53-62) years, Child-Turcotte-Pugh 7 (6-9), and model for end-stage liver disease 10 (7-16). FNA material was adequate in 92% patients, metastasis in 15 (30%), granulomatous lymphadenopathy in 4 (8%), and reactive change in 27 patients (54%). The material was inadequate for diagnosis in 4 (8%) patients. Thus, EUS-guided FNA precluded transplantation in 30% of patients with lymphadenopathy, and 4 (8%) patients received anti-tubercular therapy before liver transplantation. CONCLUSION: In patients with HCC and lymphadenopathy, EUS-guided FNA detected metastatic disease and precluded liver transplantation in approximately one third of patients.

Impact and safety of endoscopic ultrasound guided fine needle aspiration on patients with cirrhosis and pyrexia of unknown origin in India.

BACKGROUND AND AIMS: Etiologic diagnosis of pyrexia of unknown origin is important in patients with cirrhosis for optimal management and to prevent flare up of infectious disease after liver transplantation. However, there is very limited literature available on this subject. The present study aimed to examine the safety and impact of endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) in patients with cirrhosis. METHODS: The study was conducted between January 2014 and January 2016 at a tertiary care center. A total of 50 (47 lymph nodes, 3 adrenal) EUS guided FNAs were performed in 46 patients. Data are presented as median (25 - 75 IQR). RESULTS: The study included 46 patients (40 males) whose mean age was 47.9 ±â€Š11.1 (SD) years; mean Child-Turcotte-Pugh (CTP) score and mean MELD (Model for End-Stage Liver Disease) score were 10 (8 - 11) and 18 (12 - 20), respectively. The Child Pugh class was A in 4, B in 14, and C in 28 (including three patients with adrenal FNAs). Indications for FNA were pyrexia of unknown origin and lymphadenopathy on CT imaging. The cytopathological diagnoses were metastatic disease in 1 (adrenal), granulomatous change in 10 (6 positive with acid fast bacilli stain), histoplasmosis in three (two adrenals, one lymph node), 32 lymph nodes were reactive and four lymph node FNAs showed inadequate cellularity. The pathologic nodes had significantly lower long-to-short axis ratio [1.25 (1.09 - 1.28) versus 1.46 (1.22 - 1.87), P = 0.020]; a higher proportion of hypoechoic echotexture (5 versus 3, P = 0.017), and sharply defined borders (4 versus 2, P = 0.029). Complications included mild hepatic encephalopathy related to sedation in two patients with Child's C status. CONCLUSION: EUS guided FNA is safe in patients with cirrhosis and modified the management in 14/46 (30.4 %) patients.

Adrenal Histoplasmosis in Immunocompetent Patients Presenting as Adrenal Insufficiency.

OBJECTIVE: Histoplasmosis is an infectious disease caused by the dimorphic fungus Histoplasma capsulatum, endemic in central and eastern states of United States, South America and Africa. India is considered to be non-endemic area for histoplasmosis. Disseminated histoplasmosis may affect almost all systems. Disseminated histoplasmosis with asymptomatic adrenal involvement has been described in immunocompromised patients; whereas isolated adrenal involvement with adrenal insufficiency as the presenting manifestation of the disease is rare. MATERIAL AND METHOD: Twelve patients from a non-endemic area with adrenal histoplasmosis, who were immunocompetent and diagnosed as adrenal histoplasmosis by cytology/histopathology between January 2012 to December 2014 were studied. 18F-FDG PET/CT (fluorodeoxyglucose positron emission tomography/computed tomography) was used to assess the extent of involvement. RESULTS: There were a total of 12 immunocompetent males (mean age: 56.9 years). Ten patients had bilateral adrenal involvement and two had a unilateral left adrenal mass. All the patients had histopathologically/cytologically proven adrenal histoplasmosis. Two patients had simultaneous histoplasmosis of other sites, one in the epiglottis and the other in the alveolus. 18F-FDG PET/CT was performed in 10 patients showing high FDG uptake in the adrenals. All these patients received Amphotericin B and/or Itraconazole treatment that led to symptomatic improvement. CONCLUSION: A diagnosis of invasive fungal infection requires a high index of suspicion, especially in immunocompetent patients who present with nonspecific symptoms, clinical signs, laboratory and radiological features that can resemble adrenal neoplasms. Clinical specimens must be sent for cytopathology/histopathology together with fungal culture for a definite diagnosis and appropriate management.

Endoscopic ultrasound characteristics of tubercular lymphadenopathy in comparison to reactive lymph nodes.

AIM: Tuberculosis is a common disease in India with significant morbidity and mortality. Limited data is available on the description of tubercular lymphadenopathy on endoscopic ultrasound. METHODS: Retrospective data of 116 lymph nodes in 113 patients was evaluated at a tertiary care center. Lymphadenopathy in the mediastinum and abdomen were included. The study was aimed at identifying the endoscopic ultrasound (EUS) features of tubercular lymphadenopathy and comparing them with reactive lymphadenopathy in patients with pyrexia of unknown origin. RESULTS: The following features were suggestive of tubercular lymphadenopathy (n = 55) as compared to reactive lymphadenopathy (n = 61): hypoechoic echotexture (94.5% vs. 75.4%, p 0.004), patchy anechoic/hypoechoic areas (30.2% vs. 0%, p = 0.000), calcification (24.5% vs. 0%, p = 0.000), sharply demarcated borders (34.5% vs. 9.8%, p = 0.001), pus like material on aspirate (18.2% vs. 0%, p 0.000), and conglomeration of lymph nodes (10.9% vs. 0%, p = 0.009). The tubercular lymph nodes were significantly larger than reactive nodes at long axis and short axis diameter (2.4 ± 1.1 vs. 1.6 ± 0.6 cm, p < 0.001 and 1.5 ± 0.7 vs. 0.9 ± 0.3 cm, p = 0.001 respectively). On cytopathological examination, presence of necrosis (92.7% vs. 0%, p = 0.000) and granulomas (78.1% vs. 0%, p = 0.000) favored tubercular as compared to reactive lymphadenopathy. CONCLUSION: EUS features like hypoechoic echotexture, patchy anechoic/hypoechoic areas, calcification, sharply demarcated borders, conglomeration, purulent aspirate, larger size, and cytopathological presence of necrosis/granulomas are suggestive of tubercular as compared to reactive lymphadenopathy.

Endoscopic ultrasound-guided fine-needle aspiration of the adrenal glands: analysis of 21 patients.

BACKGROUND/AIMS: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) cytology of adrenal masses helps in etiological diagnosis. The aim of this study was to evaluate the diagnostic yield of EUS-FNA of adrenal masses in cases where other imaging methods failed and/or were not feasible. METHODS: Twenty-one consecutive patients with adrenal masses, in whom adrenal FNA was performed because conventional imaging modalities failed and/or were not feasible, were prospectively evaluated over a period of 3 years. RESULTS: Of the 21 patients (mean age, 56±12.2 years; male:female ratio, 2:1), 12 had pyrexia of unknown origin and the other nine underwent evaluation for metastasis. The median lesion size was 2.4×1.6 cm. Ten patients were diagnosed with tuberculosis (shown by the presence of caseating granulomas [n=10] and acid-fast bacilli [n=4]). Two patients had EUS-FNA results suggestive of histoplasmosis. The other patients had metastatic lung carcinoma (n=6), hepatocellular carcinoma (n=1), and adrenal lipoma (n=1) and adrenal myelolipoma (n=1). EUS results were not suggestive of any particular etiology. No procedure-related adverse events occurred. CONCLUSIONS: EUS-FNA is a safe and effective method for evaluating adrenal masses, and it yields diagnosis in cases where tissue diagnosis is impossible or has failed using conventional imaging modalities.

Extraoral plasmablastic lymphoma detected using ascitic fluid cytology and flow cytometry: a case report with a review of the literature.

BACKGROUND: Plasmablastic lymphoma (PL) is a relatively new category of lymphoma, which has been considered to be found predominantly in the oral cavity and has a strong association with HIV. CASE: We report a case of extraoral/mesenteric PL detected using cytological examination of ascitic fluid assisted by flow cytometric (FC) analysis. The cells were positive for CD38, CD138, CD10, CD45 and CD56 and negative for CD3, CD19, CD20 and CD79a, with cytoplasmic lambda light-chain restriction. We also reviewed 67 cases of extraoral PL from the available literature and found them to be less often associated with HIV (than oral PL), occurring mostly in males aged 30-60 years, with the most common extraoral site being the anorectal region. CONCLUSION: A high index of suspicion at the level of the cytopathologist is imperative for identifying lymphoma cells in a body fluid. A rare entity like PL can also be diagnosed on cytology assisted by ancillary techniques (like FC), without the need for a biopsy. We also suggest that the minimum panel to diagnose PLs should include CD138, MUM-1, Ki-67, ALK-1, CD3, immunoglobulin light-chains, CD20 and PAX5.