Endoscopic ultrasound-guided fine-needle aspiration in the diagnosis of adrenal lesions

Endoscopic ultrasound-guided tissue acquisition beyond the pancreas

Endoscopic ultrasound (EUS) offers the ability to obtain tissue material via a fine needle under direct visualization for cytological or pathological examination. Prior studies have looked at EUS tissue acquisition; however, most reports have been centered around lesions of the pancreas. This paper aims to review the literature on EUS tissue acquisition in other organs (beyond the pancreas) such as the liver, biliary tree, lymph nodes, and upper and lower gastrointestinal tracts. Furthermore, techniques for obtaining tissue samples under EUS guidance continue to evolve. Specifically, some of the techniques that endoscopists employ are suction techniques (i.e., dry heparin, dry suction technique, wet suction technique), the slow pull technique, and the fanning technique. Apart from acquisition techniques, the type and size of the needle utilized play a major role in the quality of samples. This review describes the indications for tissue acquisition for each organ, and also describes and compares the various tissue acquisition techniques, as well as the different needles used according to their shape and size.

Unilateral adrenal tuberculosis whose computed tomography imaging characteristics mimic a malignant tumor: A case report

BACKGROUND

Adrenal tuberculosis usually presents with bilateral involvement. It has special characteristics in computed tomography (CT) images, such as small size, low attenuation in the center, and peripheral rim enhancement, which differ from those of primary tumors.

CASE SUMMARY

A 42-year-old female presented to the hospital with low back pain. She had been diagnosed with hypertension as well as pulmonary and cerebral tuberculosis but denied having any fever, fatigue, anorexia, night sweats, cough, or weight loss. Abdominal CT revealed an irregular 6.0 cm × 4.5 cm mass with uneven density in the right adrenal gland, while the left adrenal gland was normal. No abnormalities were observed in plasma total cortisol (8 am), adrenocorticotropic hormone, aldosterone/renin ratio, blood catecholamines, or urine catecholamines. A fine-needle aspiration biopsy of the right adrenal gland provided evidence of tuberculosis. After three years of anti-tuberculosis treatments, the large mass in the right adrenal gland was reduced to a slight enlargement.

CONCLUSION

This is a case of unilateral adrenal tuberculosis with CT imaging characteristics mimicking those of a malignant tumor. Extended anti-tuberculosis therapy is recommended in such cases.

Adrenocortical Carcinoma Diagnosed by Endoscopic Ultrasound-guided Fine-needle Aspiration

Adrenocortical carcinoma (ACC) is a rare malignancy with a very poor prognosis. A 77-year-old man underwent imaging studies due to poorly controlled hypertension, which revealed a mass measuring 43 mm in diameter near the left adrenal gland. There were no findings indicative of pheochromocytoma. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed for the preoperative pathological evaluation, and the findings indicated a possibility of ACC. Based on these results, curative surgery was performed. If the diagnosis of pheochromocytoma is excluded, then EUS-FNA for adrenal lesions is relatively safe. It can also be used for the preoperative diagnosis of ACC.

Endoscopic Ultrasound-Guided Transgastric Puncture and Drainage of an Adrenal Abscess in an Immunosuppressed Patient: A Case Report

Adrenal gland infection is a clinical entity of great importance, but it is a largely unrecognized pathology. Immunosuppressed individuals are at a higher risk of presentation. Herein, we describe a young female patient, recently diagnosed with HIV, who presented with severe sepsis due to methicillin-resistant Staphylococcus aureus, associated with a left adrenal abscess. She was initially treated with antibiotics; however, due to the persistence of the systemic inflammatory response and bacteremia, endoscopic ultrasound-guided drainage was performed. This procedure was successful in resolving the clinical situation. Endoscopic ultrasound-guided adrenal gland drainage can be a safe, efficacious, and minimally invasive option for managing antibiotic-refractory adrenal abscesses in immunosuppressed patients.

Clinical impact of endoscopic ultrasound in the study of adrenal gland: cytomegalovirus infection mimicking a neoplasic hypercaptation in PET

A 71-year-old woman with stage IV follicular lymphoma in complete remission since 2006. In March 2019, chemotherapy treatment was initiated due to a relapse with pulmonary involvement. At three months, the patient presented a bad general condition and fever. A positron emission tomography (PET) showed abnormal metabolic activity in the left adrenal gland (AG), suggestive of lymphoma recurrence.

EUS-guided tissue acquisition in the study of the adrenal glands: Results of a nationwide multicenter study

Background

There are limited data about the role of endoscopic ultrasound-guided tissue acquisition (EUS-TA), by fine needle aspiration (EUS-FNA) or biopsy (EUS-FNB), in the evaluation of the adrenal glands (AG). The primary aim was to assess the diagnostic yield and safety. The secondary aims were the malignancy predictors, and to create a predictive model of malignancy.

Methods

This was a retrospective nationwide study involving all Spanish hospitals experienced in EUS-TA of AGs. Inclusion period was from April-2003 to April-2016. Inclusion criteria: all consecutive cases that underwent EUS-TA of AGs. EUS and cytopathology findings were evaluated. Statistical analyses: diagnostic accuracy of echoendoscopist’s suspicion using cytology by EUS-TA, as gold standard; multivariate logistic regression model to predict tumor malignancy.

Results

A total of 204 EUS-TA of AGs were evaluated. Primary tumor locations were lung70%, others19%, and unknown11%. AG samples were adequate for cytological diagnosis in 91%, and confirmed malignancy in 60%. Diagnostic accuracy of the endosonographer's suspicion was 68%.

The most common technique was: a 22-G (65%) and cytological needle (75%) with suction-syringe (66%). No serious adverse events were described. The variables most associated with malignancy were size>30mm (OR2.27; 95%CI, 1.16–4.05), heterogeneous echo-pattern (OR2.11; 95%CI, 1.1–3.9), variegated AG shape (OR2.46; 95%CI, 1–6.24), and endosonographer suspicion (OR17.46; 95%CI, 6.2–58.5). The best variables for a predictive multivariate logistic model of malignancy were age, sex, echo-pattern, and AG-shape.

Conclusions

EUS-TA of the AGs is a safe, minimally invasive procedure, allowing an excellent diagnostic yield. These results suggest the possibility of developing a pre-EUS procedure predictive malignancy model.

Recent advancement in EUS-guided fine needle sampling

EUS-guided tissue acquisition technique plays an essential role for evaluation of gastrointestinal tumors. Several components affect the yield of EUS-guided tissue acquisition outcomes such as sampling techniques, use of ROSE (rapid onsite evaluation), training and experience, and needle designs. In this review we discuss advancement in EUS-guided fine needle sampling.

First Reported Case of Endoscopic Ultrasound-Guided Core Biopsy Yielding Diagnosis of Primary Adrenal Leiomyosarcoma

Primary adrenal leiomyosarcoma (PAL) is an extremely rare mesenchymal tumor with only a few isolated case reports in the medical literature. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) or endoscopic ultrasound-guided core biopsy (EUS-CB) is a safe, effective modality for sampling lesions in the gastrointestinal tract and adjacent organs, including the adrenal glands. We describe the case of a 50-year-old male presenting with abdominal pain and unintentional weight loss over the course of one year. CT imaging revealed an 8.1 cm heterogeneous left adrenal mass with PET-confirmed metastases to the liver and lung. Pheochromocytoma was ruled out. Adrenal cortical carcinoma was the other critical differential diagnosis. As the patient was not a candidate for surgery, an EUS-FNA and CB were performed on this left adrenal mass revealing a spindle cell neoplasm with extensive necrosis confirming the diagnosis of primary leiomyosarcoma. The patient was treated with chemotherapy with palliative radiation. This case demonstrates the utility of EUS-FNA or CB as modalities that can aid in the diagnosis of adrenal lesions in specific circumstances.

Preliminary investigation of the function of hsa_circ_0006215 in pancreatic cancer

The incidence of pancreatic cancer is increasing annually in Asia as a whole. Pancreatic cancer ranks sixth in terms of incidence of all malignant tumors. Circular RNA (circRNA) is a type of non-coding RNA which forms a covalently closed continuous loop. CircRNA is extensively expressed in the cytoplasm, and is markedly conservative and stable. MicroRNA (miR)-378a-3p and human (hsa)_circ_0006215 were detected using the reverse transcription-quantitative polymerase chain reaction (RT-qPCR) in tissue and cells. Western blot analysis detected the SERPINA4 and hsa_circ_0006215 expression in tissue. A Cell Counting Kit-8 assay was used to determine cell stability. Flow cytometry was used to determine the cell apoptotic rate. Transwell assays were used to determine cell migration. hsa_circ_0006215 was identified as a significantly upregulated circRNA. RT-qPCR results verified that, in 30 samples of pancreatic cancer tissue and paracancerous tissue, hsa_circ_0006215 expression was increased in pancreatic cancer tissue, miR-378a-3p expression was decreased in pancreatic cancer tissue, and SERPINA4 expression was increased in pancreatic cancer tissue (P<0.05). Using bioinformatics database and bioinformatics analysis, the interaction network of hsa_circ_0006215 indicated that this circRNA was most likely to regulate the expression of miR-378a-3p. Further interaction analysis revealed that the SERPINA4 gene was a regulatory target gene most likely to have an influence. The present study identified the effects of hsa_circ_0006215, miR-378a-3p and SERPINA4 signaling pathways in pancreatic cancer cells.

A quarter century of EUS-FNA: Progress, milestones, and future directions

Tissue acquisition using EUS has considerably evolved since the first EUS-FNA was reported 25 years ago. Its introduction was an important breakthrough in the endoscopic field. EUS-FNA has now become a part of the diagnostic and staging algorithm for the evaluation of benign and malignant diseases of the gastrointestinal tract and of the organs in its proximity, including lung diseases. This review aims to present the history of EUS-FNA development and to provide a perspective on the recent developments in procedural techniques and needle technologies that have significantly extended the role of EUS and its clinical applications. There is a bright future ahead for EUS-FNA in the years to come as extensive research is conducted in this field and various technologies are continuously implemented into clinical practice.

Endoscopic ultrasound-guided fine-needle aspiration of enlarged adrenals in patients with pyrexia of unknown origin: A single-center experience of 52 cases

BACKGROUND

Fine-needle aspiration (FNA) of adrenals is needed in patients with pyrexia of unknown origin (PUO) and adrenal enlargement in absence of other diagnostic clues. Adrenals are easily accessible by endoscopic ultrasound (EUS) due to proximity; however, there is no systemic study available on FNA of adrenals in patients with PUO. The aim of this study was to evaluate the diagnostic yield and safety of EUS-FNA of enlarged adrenal in patients with PUO.

METHODS

Data was analyzed from October 2010 to September 2016 at a single tertiary care center in northern India. EUS-FNA of enlarged adrenals was done in 52 patients for the etiological diagnosis of PUO in whom a definitive diagnosis could not be made with other means.

RESULTS

The mean age was 48±14 years; 36 were males and 16 were females. EUS-FNA was done from the left adrenal in 50 patients and from the right sample in 2 patients. A technical success was achieved in 100% cases. The 19-G needle was used in the majority (75%) to the presence of necrotic areas in adrenals; median numbers of passes were 2. The cytopathological diagnoses were tuberculosis (n = 36), histoplasmosis (n = 13), lymphoma (n = 2), and metastasis from undiagnosed neuroendocrine tumor of lung (n = 1). Thus, a diagnosis could be made in 52/52 (100%) patients. None of the patients had any procedure-related complications.

CONCLUSIONS

EUS-FNA is a safe and effective method for evaluating etiology of PUO in patients with adrenal enlargement.

Present status and perspectives of endosonography 2017 in gastroenterology

Endoscopic ultrasound has become an essential tool in modern gastroenterology and abdominal surgery. Compared with all other endoscopic methods, it has the most potential for innovation and its future looks bright. Thus, we compiled this summary of established and novel applications of endoscopic ultrasound methods to inform the reader about what is already possible and where future developments will lead in improving patient care further. This review is structured in four parts. The first section reports on developments in diagnostic endoscopic ultrasound, the second looks at semi-invasive endoscopic ultrasound, and the third discusses advances in therapeutic endoscopic ultrasound. An overview on the future prospects of endoscopic ultrasound methods concludes this article.