EUS and fine-needle aspiration in the evaluation of mediastinal masses superior to the aortic arch

Endoscopic ultrasound-guided drainage for mediastinal abscess: first report of bridge to surgery for esophageal cancer

Perforated esophageal cancer rarely results in the formation of mediastinal abscess. Endoscopic ultrasound (EUS)-guided abscess drainage (AD) has increasingly been used in the management of abscesses in locations that are difficult to treat percutaneously. We describe a case of EUS-AD for mediastinal abscess due to perforating esophageal cancer and successful bridge to surgery. A 71-year-old man with suspected esophageal issues was referred to our hospital. Computed tomography showed an esophageal cancer perforating the mediastinum, forming a mediastinal abscess. EUS-AD was planned before curative resection, because there was little improvement in inflammatory response with antimicrobial therapy. The mediastinal abscess cavity was confirmed on EUS and punctured using a 19-G needle, and then, a 0.025-inch guidewire was placed in the abscess cavity. The fistula was dilated with a 7-Fr dilator and a 6-Fr, single-pigtail nasobiliary tube was placed in the abscess cavity. One month later, clinical signs had improved and curative surgery was performed. Postoperative adjuvant therapy was administered using fluorouracil/cisplatin therapy. As of 2 years postoperatively, the patient remains free of recurrence.

Endoscopic ultrasound in the diagnosis of mediastinal diseases

EUS is a useful tool for diagnosis of mediastinal diseases. EUS-FNA plays an important role in staging of lung cancer and in tissue acquisition in patients with mediastinal masses. In this review, the following issues will be addressed: EUS-FNA and EBUS-TBNA, metastatic mediastinal lymph nodes diagnosed by EUS, EUS in assessment of mediastinal lymph node status for staging of lung cancer, mediastinal lymphoma diagnosed by EUS, sarcoidosis and tuberculosis diagnosed by EUS.

The oncocyte that went places: diagnosis with EUS-guided FNA

Although uncommon, Hurthle cell neoplasms have a characteristic histologic and cytologic features which often aid in the diagnosis of these lesions. In fine needle aspiration biopsies, determining malignant potential on cytologic features is challenging unless other evidence of malignancy (such as metastases) are known. The role of EUS-guided FNA in diagnosing superior mediastinal masses has been described previously. It's role in evaluating subcarinal metastases from lung cancer primaries have also heen studied. However we describe metastatic thyroid Hurthle cell carcinoma to the subcarina diagnosed through EUS-guided FNA combining the unique cytologic features o Hurthle cell neoplasms and the versatility ofthe endoscopic ultrasound to reach a diagnosis in this unusual neoplasm.

Endoscopic ultrasound-guided fine-needle aspiration with aspirate assay to diagnose suspected mediastinal parathyroid adenomas

OBJECTIVE

To describe our experience with mediastinal parathyroid adenomas diagnosed by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and measurement of parathyroid hormone.

METHODS

We describe the clinical and pathologic findings and diagnostic techniques used in 2 study patients.

RESULTS

Patient 1 was a 54-year-old man with persistently elevated serum calcium and parathyroid hormone concentrations despite removal of a right inferior parathyroid adenoma. An echoendoscope was used to identify the lesion and to perform FNA. The parathyroid hormone concentration measured in the aspirated material was 1800 pg/mL. Pathologic examination of the resected specimen revealed a 29.7-g parathyroid adenoma. Patient 2 was an 86-year-old woman with recurrent hyperparathyroidism. A linear array echoendoscope was used to perform FNA of the lesion in her mediastinum. The parathyroid hormone concentration measured in the aspirated specimen was 6905 pg/mL.

CONCLUSIONS

Preoperative localization of recurrent or persistent hyperparathyroidism is often difficult. EUS-FNA allows evaluation of masses, such as those found in the mediastinum, that are poorly evaluated by other imaging modalities. This technique may be a useful adjunct in diagnosing mediastinal parathyroid adenomas.

EUS-FNA as the initial diagnostic modality in centrally located primary lung cancers

BACKGROUND AND AIMS

The need to safely and accurately diagnose lung neoplasms is crucial as the only prospect for a cure is surgical resection. A small amount of data exists on the use of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) as the initial diagnostic modality of primary lung cancer.

METHODS

We performed a retrospective review of an established prospective database of all patients undergoing EUS-FNA of a primary lung neoplasm adjacent to the esophagus during January 2001 to August 2005 in one tertiary care center. The indications for the procedure, diagnostic accuracy, and complications were reviewed.

RESULTS

A total of 17 cases (9 females, 8 males) were identified. The mean age was 66 (SD 10.6). There were 9 lesions within the hilum and 8 lesions within the upper lobes. The median size of the lung lesions was 5 (range 2 to 12)x4 (range 2 to 9) cm. The median and mean number of FNA passes was 3. All the procedures provided an accurate diagnosis of the primary lung lesion without need for further intervention. One patient with active hemoptysis was transiently hospitalized for aspiration pneumonia postprocedure.

CONCLUSIONS

EUS-FNA is a safe, relatively cost-effective, and accurate initial diagnostic modality for the diagnosis of lung lesions adjacent to the esophagus or invading the mediastinum. Although further randomized prospective trials are warranted, this modality should be considered as a first step in the diagnostic armamentarium in centrally located lung lesions.

Preoperative diagnosis of a mediastinal granular cell tumor by EUS-FNA: a case report and review of the literature

We report the first case of a posterior mediastinal granular cell tumor initially diagnosed on cytologic material obtained via endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in a 51-year-old male with a prior history of colon cancer. Aspirates obtained were cellular and composed of polygonal cells with abundant granular cytoplasm and small, round dark nuclei. An immunoperoxidase stain performed on the cell block for antibodies to S-100 protein showed strong, diffuse staining of the cytoplasmic granules. Electron microscopy performed on the cell block revealed numerous cytoplasmic lysosomes. This is the first case report in the English literature of a definitive preoperative diagnosis of a mediastinal granular cell tumor utilizing material obtained via EUS-FNA.

Endoscopic Ultrasound for Thoracic Malignancy: A Review

Accurate cancer staging is critical in providing the most appropriate therapy for patients with lung cancer. The decision to attempt a curative surgery or avoid an unnecessary surgery is dependent on accurate staging. In the case of non-small-cell lung cancer (NSCLC), the most important parameters for optimal treatment and prognosis are the presence of cancer spread to the lymph nodes within the mediastinum and to distant organs. Endoscopic ultrasound (EUS) has become an important tool for the assessment of mediastinal lymph nodes and in some cases, distant organ metastases, because of its minimally invasive access to these sites through a transesophageal, transgastric, or transduodenal approach. The capability of performing fine needle aspiration (FNA) has greatly improved the accuracy and acceptability of EUS for lung cancer staging. This review will outline the basic principals of EUS-guided lung cancer staging and EUS-FNA techniques and outline the indications and contraindications to EUS staging of thoracic malignancy.

Endoscopic Ultrasound in Non–Small Cell Lung Cancer and Negative Mediastinum on Computed Tomography

Despite technical advances in staging non-small cell lung cancer (NSCLC), accurate staging remains a challenge. Endoscopic ultrasound is useful in staging NSCLC when lymphadenopathy is present on a computed tomography (CT), but its role in the absence of lymphadenopathy on CT has not been well defined. Therefore, we sought to determine the clinical impact of endoscopic ultrasound (EUS) in staging NSCLC in absence of mediastinal lymphadenopathy on CT. Seventy-six patients with NSCLC with absence of mediastinal lymphadenopathy on CT were enrolled and followed prospectively. EUS-guided fine-needle aspiration was performed on sites that were suspicious for metastases. Surgical pathology after thoracotomy was used as the reference standard for assessing accuracy. Sixty-two (86%) patients underwent surgery, and 10 (13%) did not. EUS precluded surgery in 9 patients (12%) and influenced management in 18 (25%) of all patients in this study. EUS detected malignant mediastinal lymphadenopathy more frequently in patients with lower lobe and hilar cancers combined compared with upper lobe cancers (p = 0.004). EUS played a significant role in identifying patients with unresectable (N3) NSCLC when adenopathy was not present on CT imaging and appears to be more sensitive in detecting lymph node metastases in lower lobe and hilar NSCLC compared with upper lobe NSCLC.

Endoscopic ultrasound and staging of non-small cell lung cancer

This article outlines the basic principals of lung cancer staging and EUS-FNA techniques and suggests appropriate and inappropriate indications of EUS-FNA for lung cancer.

EUS-FNA of recurrent postoperative extraluminal and metastatic malignancy

BACKGROUND

EUS-guided FNA is safe and accurate for the diagnosis of benign or malignant neoplasia and lymphadenopathy; however, its role in the diagnosis of recurrent malignancy is not well described.

METHODS

A prospectively updated EUS-guided FNA cytology database was used to identify patients in whom a diagnosis of postoperative, recurrent, extraluminal, or metastatic malignancy was made over a 5-year period. Only patients with a positive EUS-guided FNA were included in the analysis. All had undergone surgery for the primary malignancy and were in clinical and/or radiographic remission before the initial suspicion of tumor recurrence.

RESULTS

Twenty-one patients underwent EUS-guided FNA of 21 lesions (19 masses, 2 lymph nodes) because of a suspicion of recurrent malignancy based on CT (n = 17) or EUS (n = 4) findings. Median time from the initial diagnosis to recurrence was 26 months (range 5-276 months). Lesions were located in the pancreas (9 patients), mediastinum (7), liver (3), perigastric region (1), and liver hilum (1). EUS-guided FNA (mean number of needle passes, 4.5; range 2-8) obtained diagnostic material for recurrent malignancy in all patients as follows: esophageal (6 patients), renal cell (6), pancreatic (2), breast (2), colon (2), bile duct (1), Ewing's sarcoma (1), and lung (1) cancer. No complication was encountered. Transgastric EUS-guided FNA (4 patients), distal, or transesophageal EUS-FNA (2) proximal to a surgical anastomosis was required to confirm recurrence in all 6 patients with esophageal cancer. The initial cytologic diagnosis of recurrent malignancy was made by EUS in 20 of 21 (95%) patients. One patient with recurrent breast cancer had CT-guided FNA of a right lung mass preceding EUS-guided FNA of an AP window lymph node.

CONCLUSIONS

EUS-guided FNA can detect and safely diagnose recurrent malignancy in the mediastinum, retroperitoneum, and liver. When possible, correlation between EUS-guided FNA cytology and original tumor histopathology/cytology, or the use of immunostaining to confirm the diagnosis, is recommended.

Mediastinal lymph node involvement in potentially resectable lung cancer: comparison of CT, positron emission tomography, and endoscopic ultrasonography with and without fine-needle aspiration

PURPOSE

A prospective comparison of three imaging techniques: thoracic CT, positron emission tomography (PET), and endoscopic ultrasonography (EUS) with fine needle aspiration (FNA), each performed under routine conditions, for the detection of metastatic lymph nodes metastases in patients with lung cancer considered for operative resection.

PATIENTS AND METHODS

Following bronchoscopic evaluation, CT, PET, and EUS were performed to evaluate potential mediastinal involvement in 33 consecutive patients with bronchoscopic biopsy/cytology proven (n = 25) or radiologically suspected (n = 8) lung cancer prior to surgery. Surgical histology was used as "gold standard" to confirm the diagnosis of the primary tumor and the mediastinal status in all patients. Histology proved non-small cell lung cancer in 30 patients, neuroendocrine tumor in 1 patient, and benign disease in 2 patients.

RESULTS

The mean age of the study group was 61.5 years (range, 41 to 80 years; 23 male patients). CT, PET, and EUS detected mediastinal lymph nodes (size, 0.4 to 1.6 cm) in 15, 14, and 27 patients (21 of which were suspected to be malignant on EUS), respectively. With respect to the correct prediction of mediastinal lymph node stage, the sensitivities of CT, PET, and EUS were 57%, 73%, and 94%. Specificities were 74%, 83%, and 71%. Accuracies were 67%, 79%, and 82%. Results of PET could be improved when combined with CT (sensitivity, 81%; specificity, 94%; accuracy, 88%). The specificity of EUS (71%) was improved to 100% by FNA cytology (EUS-guided FNA), which gave a tissue diagnosis including tumor type, without complications.

CONCLUSIONS

No single imaging method alone was conclusive in evaluating potential mediastinal involvement in apparently operable lung cancer and routine clinical conditions. A tissue diagnosis is extremely helpful. Because FNA can be performed at the same time as EUS, this combination emerged as the most useful technique in the evaluation of even very small mediastinal metastases of lung cancer. CT seems necessary additionally to evaluate the pretracheal region as well as the rest of the thorax, and PET may be valuable to detect distant metastases.