Analysis of cytological specimens from mediastinal lesions obtained by endoscopic ultrasound-guided fine-needle aspiration

Performance of EUS-FNA and EUS-B-FNA for the diagnosis of left adrenal glands metastases in patients with lung cancer: A systematic review and meta-analysis

OBJECTIVES

For diagnosing left adrenal gland metastasis in lung cancer, clinical guidelines recommend to perform EUS, but EUS-B (EUS using an EBUS-scope) is increasingly being used. We evaluated the diagnostic performance of both procedures.

MATERIALS AND METHODS

We did a systematic review (PROSPERO, CRD42023416205) and searched MEDLINE and EMBASE on 04-July-2023 for studies evaluating EUS and/or EUS-B in diagnosing left adrenal gland metastases in adults with (suspected) lung cancer. Outcomes were: (1) ability to visualize the left adrenal gland, (2) ability to sample (in those with successful visualization and in whom sampling was attempted), (3) ability to obtain adequate material (in those with successful sampling), (4) malignancy detection rate (in those with successful sampling), and (5) remaining risk of malignancy (in those with a negative EUS(-B)-FNA and undergoing a reference standard). We performed random-effects meta-analyses.

RESULTS

We included 19 studies (EUS: n = 11, EUS-B: n = 6, both: n = 2), covering 1712 patients. All studies had high (n = 18) or unclear (n = 1) risk of bias (QUADAS-2). Average ability to visualize the left adrenal gland was 0.94 (95 %CI 0.82-0.98; n = 7 studies). Average ability to sample was 1.00 (95 %CI 0.99-1.00; n = 9). Average ability to obtain adequate material was 0.96 (95 %CI 0.93-0.98; n = 18). Average malignancy detection rate was 0.42 (95 %CI 0.34-0.49; n = 18). Remaining risk of malignancy was 0.07 (95 %CI 0.04-0.12; n = 8). Ability to visualize was slightly higher for EUS (0.99; 95 %CI 0.90-1.00) than EUS-B (0.84; 95 %CI 0.70-0.92; p = 0.025), but the other performance characteristics were similar. No major complications were reported.

CONCLUSION

Both EUS and EUS-B have good performance and are safe for left adrenal gland analysis in patients with lung cancer, but the number of high-quality studies is limited and further well-constructed prospective studies are needed.

High Diagnostic Accuracy and Safety of Endoscopic Ultrasound-Guided Fine-Needle Aspiration in Malignant Lymph Nodes: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is increasingly being used for diagnosing lymphadenopathy. We aim to systematically review the accuracy of EUS-FNA in differentiating benign and malignant mediastinal and abdominal lymph nodes (LNs).

METHODS

A comprehensive literature search was performed on multiple electronic databases through February 2020. A random or fixed effect model generated the pooled sensitivity, specificity, likelihood ratio (LR), and diagnostic odds ratio (DOR) of EUS-FNA. Subgroup analyses and meta-regression were used to explore sources of heterogeneity.

RESULTS

Twenty-six studies involving 2753 patients with 2833 LNs were included. In the differential diagnosis of benign and malignant LNs, EUS-FNA had a pooled sensitivity, specificity, positive LR, and negative LR of 87% (95% confidence interval [CI] 86-90%), 100% (95% CI 99-100%), 68.98 (95% CI 42.10-113.02), and 0.14 (95% CI 0.11-0.17), respectively. The pooled rate of adverse events associated with EUS-FNA was 1.57% (95% CI 1.06-2.24%). The summary receiver operating characteristic (SROC) yielded an area under the curve (AUC) of 0.9912. EUS-FNA performed in mediastinal LNs gained a sensitivity of 85% (95% CI 81-88%), while in abdominal LNs, it reached 87% (95% CI 82-91%). The sensitivity of the subgroup with rapid on-site evaluation (ROSE) was 91% (95% CI 89-93%), while non-ROSE was 85% (95% CI 82-87%).

CONCLUSIONS

EUS-FNA is a sensitive, highly specific, and safe method for distinguishing benign and malignant mediastinal or abdominal LNs. However, the sensitivity of EUS-FNA still varies significantly among different centers.

Concise review on the comparative efficacy of endoscopic ultrasound-guided fine-needle aspiration vs core biopsy in pancreatic masses, upper and lower gastrointestinal submucosal tumors

Endoscopic ultrasound (EUS)-guided fine needle aspiration with or without biopsy (FNA/FNB) are the primary diagnostic tools for gastrointestinal submucosal tumors. EUS-guided fine needle aspiration (EUS-FNA) is considered a first line diagnostic method for the characterization of pancreatic and upper gastrointestinal lesions, since it allows for the direct visualization of the collection of specimens for cytopathologic analysis. EUS-FNA is most effective and accurate when immediate cytologic assessment is permitted by the presence of a cytopathologist on site. Unfortunately, the accuracy and thus the diagnostic yield of collected specimens suffer without this immediate analysis. Recently, a EUS-FNB needle capable of obtaining core samples (fine needle biopsy, FNB) has been developed and has shown promising results. This new tool adds a new dimension to the diagnostic and therapeutic utility of this technique. The aim of the present review is to compare the efficacy of EUS-FNA to that afforded by EUS-FNB in the characterization of pancreatic masses and of upper and lower gastrointestinal submucosal tumors.

Suitability of the CellientTM cell block method for diagnosing soft tissue and bone tumors

BACKGROUND

The diagnosis of tumors of soft tissue and bone (STB) heavily relies on histological biopsies, whereas cytology is not widely used. Cellient^TM cell blocks often contain small tissue fragments. In addition to Hematoxylin and Eosin (H&E) interpretation of histological features, immunohistochemistry (IHC) can be applied after optimization of protocols. The objective of this retrospective study was to see whether this cytological technique allowed us to make a precise diagnosis of STB tumors.

METHODS

Our study cohort consisted of 20 consecutive STB tumors, 9 fine-needle aspiration (FNAC) samples, and 11 endoscopic ultrasonography (EUS) FNACs and included 8 primary tumors and 12 recurrences or metastases of known STB tumors.

RESULTS

In all 20 cases, H&E stained sections revealed that diagnostically relevant histological and cytological features could be examined properly. In the group of 8 primary tumors, IHC performed on Cellient^TM material provided clinically important information in all cases. For instance, gastrointestinal stromal tumor (GIST) was positive for CD117 and DOG-1 and a PEComa showed positive IHC for actin, desmin, and HMB-45. In the group of 12 secondary tumors, SATB2 was visualized in metastatic osteosarcoma, whereas expression of S-100 was present in 2 secondary chondrosarcomas. Metastatic chordoma could be confirmed by brachyury expression. Two metastatic alveolar rhabdomyosarcomas were myf4 positive, a metastasis of a gynecologic leiomyosarcoma was positive for actin and estrogen receptor (ER) and a recurrent dermatofibrosarcoma protuberans expressed CD34.

CONCLUSION

In the proper clinical context, including clinical presentation with imaging studies, the Cellient^TM cell block technique has great potential for the diagnosis of STB tumors.

Endoscopic ultrasound-guided fine-needle aspiration with on-site cytopathology versus core biopsy: a comparison of both techniques performed at the same endoscopic session

BACKGROUND

Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) with bedside cytopathology is the gold standard for assessment of pancreatic, subepithelial, and other lesions in close proximity to the gastrointestinal tract, but it is time-consuming, has certain diagnostic limitations, and bedside cytopathology is not widely available.

AIMS

The goal of this study is to compare the diagnostic yield of EUS-guided FNA with on-site cytopathology and EUS-guided core biopsy.

METHODS

Twenty-six patients with gastrointestinal mass lesions requiring biopsy at a tertiary medical center were included in this retrospective analysis of a prospective cohort. Two core biopsies were taken using a 22 gauge needle followed by FNA guided by a bedside cytopathologist at the same endoscopic session. The diagnostic yield and test characteristics of EUS core biopsy and EUS FNA with bedside cytopathology were examined.

RESULTS

The mean number of passes was 3.2 for FNA, and the mean procedure time was 39.4 minutes. The final diagnosis was malignant in 92.3 %. Sensitivity and specificity were 83 % and 100 %, respectively, for FNA, and 91.7 % and 100 %, respectively, for core biopsy. Diagnostic accuracy was 92.3 % for FNA and 84.6 % for core biopsy. The two approaches were in agreement in 88.4 % with a kappa statistic of 0.66 (95 % confidence interval 0.33 - 0.99).

CONCLUSIONS

An approach using two passes with a core biopsy needle is comparable to the current gold standard of FNA with bedside cytopathology. The performance of two core biopsies is time-efficient and could represent a good alternative to FNA with bedside cytopathology.

Rapid on-site evaluation of endobronchial ultrasound-guided fine-needle aspirates: correlation of adequacy assessment and final diagnosis in patients with bronchogenic carcinoma

INTRODUCTION

We review endobronchial ultrasound-guided fine-needle aspirate samples and investigate cases with discrepancies between rapid on-site evaluation (ROSE) and final diagnosis in patients with bronchogenic carcinoma.

MATERIALS AND METHODS

Endobronchial ultrasound-guided fine-needle aspirates from 2009 to 2010 were studied. On-site adequacy assessments were compared with final diagnoses. Concordant diagnoses showed agreement between ROSE interpretation and final diagnosis. If the initial interpretation differed from the final diagnosis, the case was discordant. Slides from discordant aspirates were reviewed. Discordant results were categorized as sampling error or interpretive/screening error at ROSE.

RESULTS

A total of 340 endobronchial ultrasound-guided procedures were performed in 335 patients (168 men, 167 women, median age 65 years). Diagnostic discrepancies between ROSE and final diagnoses occurred in 65 aspirates (11%) from 51 patients with carcinoma. Of the 65 discrepant cases, 52 (83%) were subsequently called positive for carcinoma. Rescreening of slides in 47 available cases with a final positive diagnosis showed insufficient tumor for diagnosis in 28 of 47 cases (60%). The remaining 19 of 47 cases (40%) were classified as interpretive/screening errors at ROSE. Most errors occurred in aspirates called atypical or atypical suspicious, which upon rescreening were considered diagnostic (16 aspirates, 84%).

CONCLUSIONS

Initial and final diagnoses were concordant in 89% of aspirates from patients with carcinoma. All aspirates that were positive at ROSE were concordant. In discordant cases, all aspirates deemed "atypical suspicious for malignancy" and 86% of aspirates deemed "atypical cells" on ROSE had a final diagnosis of carcinoma. The majority of discordant cases with a positive final diagnosis were due to sampling (60%).

Clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis of mediastinal and intra-abdominal lymphadenopathy

INTRODUCTION

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has proven to be helpful in obtaining tissue samples from enlarged mediastinal and intra-abdominal lymph nodes. This is especially beneficial in the diagnosis and staging of malignancy. We retrospectively reviewed the clinical utility of this method at a tertiary care cancer hospital in Pakistan.

PATIENTS AND METHODS

The medical records of 183 consecutive patients referred to the gastroenterology service from August 2008 to March 2012 were reviewed in this retrospective study. The mean age of the patients at presentation was 46.7 years (range 6-87; 62% males); 119 patients had mediastinal and 64 had intra-abdominal lymphadenopathy. Major indications for referral were diagnosis of lymphadenopathy of unknown origin detected on CT scan or PET-CT, to exclude lymph node metastasis in patients with a known primary tumor and to rule out relapse of lymphoma following treatment or during follow-up. Rapid on-site evaluation (ROSE) was performed in all patients to confirm the adequacy of sampling, followed by definitive cytopathological evaluation.

RESULTS

EUS-FNA with ROSE obtained adequate tissue for cytology in 97.3% of the patients in this cohort. These results were further confirmed on final cytopathological analysis in 96.2% of patients. Two patients (1.1%) had inadequate specimens for final interpretation (97.3 vs. 96.2; p = 0.001). Clinical utility was 95% for mediastinal lymphadenopathy and 98.4% for intra-abdominal lymphadenopathy. Only 1 patient had a serious complication requiring hospitalization and this was successfully managed conservatively.

CONCLUSION

EUS-FNA is safe and has a high clinical utility in diagnosing unexplained mediastinal and intra-abdominal lymphadenopathy.

Respiratory Tract and Mediastinum

Normal cytology, abnormal and atypical cells, non-cellular components, and infectious cell changes are largely described together with benign, malignant, and neuroendocrine lesions regarding exfoliative and aspiration cytology of the lung. A separate section broadly addresses diagnostic findings and differential diagnoses in bronchoalveolar washings.

The section ‘Fine needle aspiration biopsy of mediastinal disorders’ covers in particular biopsy techniques, accuracy of liquid-based cytology, and the complex lesions of the thymus gland. Cytodiagnostic algorithms of the major benign and malignant pulmonary and mediastinal lesions and their respective differential diagnoses are additionally presented in synoptic setups.

Endobronchial ultrasound-guided transbronchial needle aspiration biopsy is useful evaluating mediastinal lymphadenopathy in a cancer center

Background:

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) biopsy is used to stage mediastinal lymph nodes in cancer patients to optimize treatment strategies. In this retrospective study, the authors determined the utility of EBUS-TBNA biopsy in the evaluation of mediastinal lymphadenopathy at a high-volume cancer center.

Materials and Methods:

The pathology database was searched for all patients who had undergone EBUS-TBNA biopsy of mediastinal lymph nodes over a one-year period. Cytologic diagnoses were correlated with clinical histories, subsequent resection, and clinical follow-up data.

Results:

Of 928 lymph node samples, 226 (24%) were diagnosed as malignant, 4 (0.4%) were suspicious for malignancy, 9 (1%) were atypical, 640 (69%) were benign, and 47 (5%) were insufficient for evaluation. In 89 (9.6%) cases, the patients had surgical resection. There was one false positive, in which the primary tumor contained infiltrating lymphocytes, had been sampled. There were five false-negative cases, which resulted from sampling errors, including two with micrometastases. The sensitivity, specificity, and positive and negative predictive value rates for EBUS-TBNA biopsy in the evaluation of mediastinal lymph nodes were 68.7% and 98.6% and 91.6% and 93.5%, respectively on a per lymph node basis. The overall clinical sensitivity, specificity, and positive and negative predictive value rates after one year clinical/radiological and histologic follow-up were 97%, 99.3%, 96.7% and 99.4%, respectively.

Conclusions:

EBUS-TBNA biopsy is a sensitive and specific method for evaluating mediastinal lymphadenopathy in patients with lung and other primary tumors.

The utility of endobronchial ultrasound-guided transbronchial needle aspiration biopsy in the diagnosis of mediastinal lymphoproliferative disorders

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) biopsy is routinely used to stage lung cancer; however, its usefulness in diagnosing lymphoproliferative disorders has not been well established. In this retrospective study, we determined the utility of EBUS-TBNA in evaluating mediastinal lymphadenopathy in patients with suspected lymphoproliferative disorders.

METHODS

The authors searched the pathology database at their institution to identify all patients who had undergone EBUS-TBNA biopsy for possible lymphoproliferative disorders. The cytologic diagnoses were correlated with concurrent and subsequent biopsy findings and clinical follow-up data.

RESULTS

Of 886 lymph nodes evaluated by EBUS-TBNA biopsy, 91 nodes from 33 patients (23 men and 10 women) were eligible. Fourteen patients had a history of lymphoma. Adequate material for diagnosis was obtained in 31 of 34 procedures (1 patient had 2 procedures). The cytologic diagnoses of the 31 adequate procedures included 19 with benign disease (8 reactive lymph nodes and 11 granulomatous inflammation), 8 with lymphoma (2 large B-cell, 2 small lymphocytic, 2 Hodgkin, 1 mantle cell, and 1 T-cell lymphoblastic), 2 with cells suspicious for Hodgkin lymphoma, and 2 cases with atypical cells.

CONCLUSIONS

EBUS-TBNA proved to be useful for evaluating mediastinal lymphadenopathy in patients with suspected lymphoproliferative disorders. Its use may decrease the need for invasive diagnostic procedures. Immediate assessment is valuable in these cases because of the need to triage material for immunophenotyping or other studies to determine optimal and clinically meaningful diagnoses.

Impact of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in lymph nodal and mediastinal lesions: a multicenter experience

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an established procedure in lung cancer (LC) staging and in the diagnosis of mediastinal masses. Most of the experiences reported refer to single specialized centers where dedicated teams of endoscopists and pathologists perform the procedure. We report the EUS-FNA experience of a cooperation group involving clinicians and cytopathologists from three hospitals. Fifty-seven consecutive EUS-FNA of mediastinal nodes in LC patients, eight mediastinal and two subdiaphragmatic masses were collected in 3 years. EUS-FNA was performed by two endoscopists and three experienced pathologists. On-site evaluation was performed in all cases by the three cytopathologists. Lymph node negative cases underwent surgery, which confirmed the cytological diagnoses but also detected two false negatives. Four of the 10 EUS cytological diagnoses of mediastinal and subdiaphragmatic masses were histologically confirmed. All EUS diagnoses were blindly reviewed by three pathologists to assess intra and interpersonal reproducibility. FNA-EUS diagnoses were: 10 inadequate (17%), 10 negative (17%), 4 suspicious (7%) and 33 positive (59%). Diagnoses of mediastinal and subdiaphragmatic masses were: relapse of lung carcinoma (3), mesenchimal tumor not otherwise specifiable (3), gastrointestinal stromal tumor (GIST) (1), esophageal carcinoma (2) and paraganglioma (1). The sensitivity attained was 85% and the specificity 100%; revision of the slides demonstrated a significant diagnostic reproducibility of the three cytopathologists (P < 0.5). The sensitivity and specificity attained were similar to those reported in the literature suggesting that experienced cytopathologists and endoscopists from different institutions can employ the same procedure reaching comparable results.

Prospective cytological assessment of gastrointestinal luminal fluid acquired during EUS: a potential source of false-positive FNA and needle tract seeding

OBJECTIVES

Endoscopic ultrasound (EUS) fine needle aspiration (FNA) can result in false-positive cytology and can also cause needle tract seeding. Our goal was to evaluate a potential cause, namely, the presence of malignant cells within gastrointestinal (GI) luminal fluid, either as a result of tumor sloughing from luminal cancers or secondary to FNA of extraluminal sites.

METHODS

During EUS, luminal fluid that is usually aspirated through the echoendoscope suction channel and discarded was instead submitted for cytological analysis among patients with cancer and benign disease. Pre- and post-FNA luminal fluid samples were collected to discern the role of FNA in inducing a positive cytology. When not performing FNA, one sample was collected for the entire examination. The final diagnosis was based on strict clinicopathological criteria and >or=2-year follow-up. This study was conducted in a tertiary referral center.

RESULTS

We assessed the prevalence of luminal fluid-positive cytology among patients with luminal (e.g., esophageal), extraluminal (e.g., pancreatic), and benign disease. Among the 140 patients prospectively enrolled with sufficient sampling and follow-up, an examination of luminal fluid cytology showed positive results for malignancy in luminal and extraluminal cancer patients, 48 and 10%, respectively. This included 8 out of 23 esophageal, 4 of 5 gastric, and 9 of 15 rectal cancers. The positive luminal fluid cytology rate with luminal cancers was not affected by performing FNA. Post-FNA luminal fluid cytology was positive in 3 out of 26 with pancreatic cancers. Cytological examination of luminal fluid aspirates did not demonstrate malignant cells in any patient with nonmalignant disease.

CONCLUSIONS

Malignant cells are commonly present in the GI luminal fluid of patients with luminal cancers and can also be found in patients with pancreatic cancer after EUS FNA. Further study is needed to determine the impact of these findings on cytological interpretation, staging, risk of needle tract seeding, and patient care and outcomes.

The utility of sonographic features during endobronchial ultrasound-guided transbronchial needle aspiration for lymph node staging in patients with lung cancer: a standard endobronchial ultrasound image classification system

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure with a high yield for lymph node staging of lung cancer. The aim of this study was to assess the utility of sonographic features of lymph nodes during EBUS-TBNA for the prediction of metastasis in patients with lung cancer and to establish a standard endobronchial ultrasound (EBUS) image classification system.

METHODS

Digital images of lymph nodes obtained during EBUS-TBNA in patients with lung cancer were categorized according to the following characteristics: (1) size (short axis) less or more than 1 cm, (2) shape (oval or round), (3) margin (indistinct or distinct), (4) echogenicity (homogeneous or heterogeneous), (5) presence or absence of central hilar structure, and (6) presence or absence of coagulation necrosis sign. The sonographic findings were compared with the final pathologic results.

RESULTS

A total of 1,061 lymph nodes were retrospectively evaluated in 487 patients. The accuracy of predicting metastatic property for each category was as high as 63.8% to 86.0%. A multivariate analysis revealed that round shape, distinct margin, heterogeneous echogenicity, and presence of coagulation necrosis sign were independent predictive factors for metastasis. Two hundred eighty-five of the 664 lymph nodes (42.9%) having at least one metastatic feature of the four categories were pathologically proven metastatic, and 96.0% of lymph nodes (381/397) were proven not metastatic when all four categories were determined as benign.

CONCLUSIONS

Sonographic features of lymph nodes based on the new EBUS imaging classification may be helpful in the prediction of metastatic lymph nodes during EBUS-TBNA.

Thymomas: review of current clinical practice

Thymomas are the most common tumors of the mediastinum. The introduction of multimodality treatment strategies, as well as novel approaches to the diagnosis of these tumors, has led to changes in the clinical management of thymomas. Here we review the literature for current clinical practice in the diagnosis, management, and treatment of thymomas.

Immunocytochemical typing of primary tumors on fine-needle aspiration cytologies of lymph nodes

The aim of this study was to analyze the role of immunocytochemistry as an ancillary method on routine FNACs of enlarged lymph nodes, using different markers. In a validating cohort study all patients had confirmatory histological and/or clinical follow-up. 10 FNACs were analyzed for the differentiation of Non-Hodgkin Lymphoma (NHL) from metastatic carcinoma (MC), 30 cases to identify the sites of metastatic unknown primary tumors and 16 cases were checked to confirm clinical suspicion of a specific MC. Accuracy to differentiate NHL from MC was 100%, 92.3% to identify a primary tumor site of MC, and 100% to confirm a clinical suspicion of a specific MC. In 7 cases, the site of the primary tumor remained clinically unknown. Application of immunocytochemical markers on the same slide used for microscopic diagnosis is a useful tool in the routine assessment of FNACs of lymph nodes.

Cytopathologic diagnoses of fine-needle aspirations from endoscopic ultrasound of the mediastinum

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration biopsy through the esophagus (EUS-FNA) or the bronchial tree (endobronchial ultrasound guided transbronchial needle aspiration [EBUS-TBNA]) may be used to obtain specimens from mediastinal structures. The accuracy of this procedure has been well documented. However, no studies have studied the reproducibility of the pathologic assessment of the aspirated material.

METHODS

A total of 102 slides from EUS-FNA or EBUS-TBNA were assessed 2 times by 4 pathologists who classified each slide to 1 of 5 diagnostic categories and judged if the aspirate came from a lymph node. Between the 2 rounds the criteria to be used in the assessment of the slides were reviewed in a limited education session. The 4 observers had at least 15 years of pathology experience, but their experience in EUS-FNA and/or EBUS-TBNA varied from almost none to more than 10 years. The kappa statistic was applied for the analysis of reproducibility.

RESULTS

The reproducibility of the diagnoses in the first round was good to excellent (kappa, 0.52-0.89). The teaching session led to a significant improvement of the reproducibility between the least and the most experienced observers (kappa ranges of 0.52-0.55 in the first round improved to 0.65-0.71 in the second round).

CONCLUSIONS

The reproducibility of the diagnosis on EBUS-TBNA and EUS-FNA is excellent among pathologists experienced with these types of samples. Pathologists who are generally experienced but have little experience with EBUS-TBNA and EUS-FNA show a steep learning curve. From a pathologic point of view, EBUS-TBNA and EUS-FNA are feasible, but only experienced pathologists should do the assessments.