Endoscopic ultrasound-guided fine-needle aspiration in the diagnosis of foregut duplication cysts: the value of demonstrating detached ciliary tufts in cyst fluid

New treatment for gastric duplication cyst: Endoscopic ultrasonography-guided fine-needle aspiration combined with lauromacrogol sclerotherapy: A case report

BACKGROUND

Gastric duplication cysts are very rare disease that are mainly diagnosed by endoscopic ultrasonographic fine-needle aspiration biopsy. In the past, this disease was usually treated with traditional surgery and rarely with minimally invasive endoscopic surgery. However, minimally invasive endoscopic therapy has many advantages, such as no skin wound, organ preservation, postoperative pain reduction, early food intake, fewer postoperative complications, and shorter post-procedure hospitalization.

CASE SUMMARY

We report a case of endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) combined with lauromacrogol sclerotherapy for pyloric obstruction due to gastric duplication cysts.

CONCLUSION

EUS-FNA combined with lauromacrogol sclerotherapy provides a new option for the treatment of gastrointestinal duplication cysts.

The Utility of Fine Needle Aspiration (FNA) Biopsy in the Diagnosis of Mediastinal Lesions

Fine needle aspiration is a minimally invasive, low-morbidity, and cost-efficient technique for the sampling of mediastinal lesions. Additionally, ancillary testing on FNA samples can be used for the refinement of diagnoses and for treatment-related purposes (flow cytometry, cytogenetics, immunohistochemistry, and molecular diagnostics). Mediastinal lesions, however, can show a variety of lineages and morphologic features, giving rise to diagnostic dilemmas. As a result, the differential diagnosis can vary widely and becomes especially challenging due to the smaller sample size on FNA and the variability in component sampling. For appropriate patient management and to determine the correct treatment strategies, accurate pathologic diagnoses are paramount. In this review, we present the cytomorphologic features together with the immunophenotypic findings of mediastinal lesions, with emphasis on the diagnostic challenges and pitfalls in FNA cytology samples, including smears and cell block sections.

Ciliated foregut cysts involving the hepatopancreaticobiliary system: a clinicopathological evaluation with focus on atypical features

AIMS

Foregut cystic malformations are rare developmental abnormalities, which may involve the hepatopancreaticobiliary tract (HPBT). These cysts are composed of inner ciliated epithelium; subepithelial connective tissue layer; smooth muscle layer; and an outer fibrous layer. While radiopathologic findings are often diagnostic, atypical location and histologic features can pose a diagnostic challenge. We aimed to study ciliated foregut cysts (CFCs) in the HPBT, assess their clinicopathological features with a focus on atypical features.

METHODS

We collected cases of CFCs involving the HPBT from three large academic medical centres. H&E-stained slides and immunohistochemical stains (where available) were reviewed for each case. Relevant demographic, clinical and pathological information was collected from the medical records.

RESULTS

21 cases were identified. The median age was 53 years (range, 3-78 years). 17 cysts were identified within the liver (segment 4 was the most common location, n=10) and 4 in the pancreas. Cysts were mostly identified incidentally (n=13), abdominal pain was a common symptom (n=5). Cyst size ranged from 0.7 to 17.0 cm (median, 2.5 cm). Radiological findings were available in 17 cases. Cilia were identified in all cases. 19 of 21 cases demonstrated the presence of a smooth muscle layer (thickness, <0.1 mm to 3.0 mm). Three cases showed gastric metaplasia, while one case revealed additional low-grade dysplasia, with features similar to intraductal papillary neoplasm of the bile duct.

CONCLUSIONS

We highlight clinicopathological features of CFCs in the HPBT. The histomorphology is usually straightforward; however, unusual location and atypical features can pose a diagnostic challenge.

Approach to Mediastinal Fine Needle Aspiration Cytology

Mediastinal fine needle aspirations are routinely encountered in cytopathology practice. Mediastinal lesions may pose diagnostic challenges owing to their rarity and locations associated with the complexity of the mediastinal anatomic structures in the thoracic cavity. Diagnosing mediastinal lesions and guiding patient management usually require correlating with clinical and radiologic findings, being familiar with cytomorphologic features and appropriately triaging the diagnostic material for ancillary testing. This review proposes a practical approach to interpret mediastinal fine needle aspirations and emphasizes potential diagnostic pitfalls for mediastinal lesions including benign cysts, thymic neoplasms, lymphoproliferative disorders, germ cell tumors, mesenchymal tumors, and metastatic tumors.

The diagnostic performance of combined conventional cytology with smears and cell block preparation obtained from endoscopic ultrasound-guided fine needle aspiration for intra-abdominal mass lesions

BACKGROUND/AIM

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is the primary method for tissue acquisition of intra-abdominal masses. However, the main limitation of cytology alone is the lack of tissue architecture and inadequate samples. This study aimed to evaluate the diagnostic performance of combined conventional cytology and cell block preparation obtained from EUS-FNA of intra-abdominal masses without Rapid On-site Evaluation (ROSE).

METHODS

Cytologic smears and cell block slides of 166 patients undergoing EUS-FNA during 2010-2015 were reviewed by an experienced cytopathologist blinded to clinical data.

RESULTS

125 patients had neoplastic lesions. Pancreatic adenocarcinoma was the most common etiology (35.5%), followed by lymph node metastasis (27.7%). The mean mass size was 2.5±1.3 cm. The mean number of passes was 1.9±1.28. Tissue adequacy for conventional cytology and cell block preparation was 78.9% and 78.1%, respectively. Factors associated with tissue adequacy were assessed. For cytology, lesions of > 2.1 cm, masses in the pancreatic body or tail, malignancy, and pancreatic cancer were positively associated with adequate cellularity. For cell block preparation, lesions of > 3 cm and malignancy were associated with increased tissue adequacy. The conventional cytology alone had a sensitivity of 68.5%, a specificity of 95.7%, and an area under the receiver operating characteristics (AUROC) of 0.821. The cell block preparation alone had a sensitivity of 65.4%, a specificity of 96%, and an AUROC of 0.807. The combined conventional cytology and cell block preparation performed significantly better than either method alone (p<0.05), as demonstrated by an increased AUROC of 0.853. Furthermore, cell block detected malignancy in 9.3% of cases where the cytologic smears failed to identify malignant cells.

CONCLUSIONS

The combined conventional cytology and cell block preparation increased the diagnostic accuracy of EUS-FNA compared to either method alone. This approach should be implemented in routine practice, especially where ROSE is unavailable.

Clinical features of gastric duplications: evidence from primary case reports and published data

Background

Alimentary tract duplications are rare congenital lesions, and only 2–8% of them are located in the stomach. Gastric duplications (GD) can lead to severe adverse events. Thus, surgical resection is required once the disease is diagnosed. The main purpose of this study is to describe the clinical features of gastric duplications and to provide evidence for the diagnosis and treatment.

Methods

A retrospective review of eight gastric duplications at two medical centers Peking University People’s Hospital (PKUPH) and Shandong Provincial Hospital from 2010 to 2020 was conducted. Furthermore, the literature search was also conducted by retrieving data from PubMed, EMBASE and Cochrane Library databases from the date of the database inception to January 15, 2021.

Results

Eight patients who were diagnosed as gastric duplications and 311 published records were included in this study. In all, 319 patients were identified: Vomiting and abdominal pain were the most frequent clinical presentations among juveniles and adults respectively. There was no difference in gender distribution (F: 53.16% vs M: 46.84%), and the cystic gastric duplications were the most common type of the gastric duplications (87.04%). More than half (53.30%) of included cases were located in the greater curvature of stomach.

Conclusions

Gastric duplications could present with a wide spectrum of symptomatology, which might be misdiagnosed easily as other diseases. For cystic gastric duplications, the optimal treatment was a complete surgical removal. But conservative treatment might be an alternative strategy for tubular gastric duplications.

Duodenal imaging on the spotlight: from A to Z

Abdominal computed tomography (CT) is frequently performed to evaluate gastrointestinal pathologic conditions. The majority of the gastrointestinal radiology literature has concentrated on the colon, stomach, and distal small bowel. The duodenum is often overlooked on imaging, namely on CT, but its anatomy (intra and retroperitoneal) and location in such close proximity to other viscera results in involvement by a multitude of primary and secondary processes, some of them exclusive to this bowel segment. While some conditions, like duplications, lipomas, and diverticula, are usually asymptomatic and are incidentalomas that have no pathologic significance, others are symptomatic and very relevant and should be recognized by every general radiologist: development conditions such as annular pancreas and gut malrotation; inflammatory processes such as ulcers and secondary involvement from pancreatitis; neoplastic conditions such as adenocarcinoma, lymphoma, or local extension from adjacent malignancies. They all can be reliably diagnosed with CT. In this article, we demonstrate the typical imaging features of various diseases involving the duodenum, such as developmental, traumatic, inflammatory, infectious, neoplastic, and postsurgical pathologic conditions in alphabetical order, focusing mainly on upper gastrointestinal series (UGIS) and CT but also some radiography, ultrasound, and magnetic resonance (MR) imaging.

Benign lesions of the mediastinum: A review with emphasis on cytology and small biopsy specimens

This review focuses on the diagnosis of select benign processes, ranging from reactive entities to heterotopic tissues to neoplasms, which may occur in the mediastinum. Currently, the mediastinum can be evaluated and biopsied with endoscopic procedures. Therefore, cytopathology specimens, fine needle aspirations, and small biopsies play an important role in the diagnosis of these lesions. In this review, an emphasis is given to relevant clinical presentations, histologic and cytologic findings, differential diagnoses, ancillary testing, and interpretation. Pitfalls are reviewed and discussed in each section. It is important for both surgical pathologists and cytopathologists to be familiar with these entities and their cytologic and histologic features that may be helpful in reaching a diagnosis.

Microforceps in the Diagnosis of Pancreatic Bronchogenic Cyst Under Endoscopic Ultrasound Guidance

Bronchogenic cysts belong in the category of foregut duplication cysts, along with esophageal and neuroenteric duplication cysts. They are often found incidentally on cross-sectional imaging. Although they are benign, patients often undergo surgical resection because of diagnostic uncertainties. We report the first case of bronchogenic cyst diagnosed with the microforceps, after previous nondiagnostic fine-needle aspirations, thus allowing the patient to avoid surgery.

Cystic Lesions of the Pancreas: Differential Diagnosis and Cytologic-Histologic Correlation

CONTEXT.—

Pancreatic cystic lesions (PCLs) are very common, and their detection is increasing with the advances in imaging techniques. Because of the major implications for management, distinguishing between neoplastic and nonneoplastic PCLs is critical. Neoplastic cysts with potential to progress into cancer include mucinous PCLs (intraductal papillary mucinous neoplasms and mucinous cystic neoplasms) and nonmucinous cysts (solid pseudopapillary tumors, serous cystic neoplasms, and neuroendocrine tumors with cystic degeneration). Nonneoplastic cysts with no risk of malignant transformation include pseudocysts, retention cysts, lymphoepithelial cysts, cystic pancreatic lymphangioma, and duplication cyst/ciliated foregut cysts. The role of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) cytology with cyst fluid analysis in the diagnosis of PCLs has evolved during the last decade; however, a definitive diagnosis on cytologic specimens is hampered by the sparse cellularity and can be challenging. EUS-FNA can play an important role to differentiate low-risk from high-risk pancreatic cysts and to distinguish between patients with cysts who need clinical follow-up versus those who require surgery.

OBJECTIVE.—

To provide an integrative approach to diagnose pancreatic cystic lesions using EUS-FNA cytology and cyst fluid analysis, along with clinical, radiologic, histologic, genetic, and molecular characteristics.

DATA SOURCES.—

The review and analysis of the latest literature describing pancreatic cystic lesions.

CONCLUSIONS.—

Accurate diagnosis of PCLs requires a multidisciplinary and multimodal team approach, including the integration of clinical findings, imaging, cytology, cyst fluid analysis, and molecular testing.

[A case of gastric duplication presenting as a retroperitoneal cystic lesion]

Gastric duplication is a rare congenital anomaly accounting to 4% of all gastrointestinal tract duplications. It is usually diagnosed pre-natally or during infancy. Retroperitoneal gastric duplication is very rare in adult patients. It is generally asymptomatic or presents with non-specific symptoms. The sensitivity of classical imaging modalities for retroperitoneal gastric duplication is weak. Retroperitoneal gastric duplication could be misdiagnosed as other retroperitoneal cystic lesions and it could be definitely diagnosed by typical findings of abdominal enhanced computed tomography (CT) and endoscopic ultrasonography (EUS) plus EUS:guided fine needle aspiration biopsy in gastric duplicated cyst. A female adult patient was diagnosed by an exceptional hospital CT as retroperitoneal cystic lesion and was admitted in our hospital in March 2019. The abdominal enhanced CT in our hospital preoperatively indicated a cystic lesion above the left kidney and the maximum cross section was 9.0 cm×5.2 cm. Lymphocysts and others should be identified and the lesion might be from the stomach. The retroperitoneal gastric duplication was not diagnosed before operation. In the operation laparoscopy revealed the cystic lesion in the retroperitoneum. The pancreas, left adrenal gland, and left kidney were compressed by the cystic lesion. The top of the lesion was connected with the small curvature of the stomach, but it was not communicated with the stomach. The retroperitoneal cystic lesion was completely excised and the surrounding organs were not damaged. The retroperitoneal gastric duplication was clearly diagnosed by the findings in the operation and the pathology of the lesion. The patient was discharged a week after surgery without gastrointestinal and pancreatic injuries. Therefore, the differential diagnosis of retroperitoneal cysts should consider the possibility of retroperitoneal gastric duplication. For patients with typical CT findings or unclear boundaries between the tumor and the stomach wall, gastric duplication could be diagnosed by EUS plus EUS:guided fine needle aspiration biopsy in the cyst. Retroperitoneal gastric duplication cyst could be completely excised by laparoscopy through abdominal cavity and the stomach wall could be completely repaired.

Gastric duplication 20 years after a partial distal gastrectomy: a case report and review of literature

Gastric duplications are the least common gastrointestinal duplications, especially in adults. Duplication cyst with an accessory pancreatic lobe is extremely rare and is even more uncommon in the setting of polysplenia. No gastric duplication after partial gastrectomy has been reported. We present a 41-year-old male diagnosed with gastric duplications with an accessory pancreatic lobe and polysplenia. Another characteristic of this case is partial gastrectomy 20 years ago without the discovery of duplication cysts. The gastric duplications, accessory pancreatic lobe and accessory spleen were successfully resected.

Adult Gastric Bronchogenic Cyst With Elevated Tumor Marker in Containing Fluid: A Case Report and Literature Review

Introduction:

Duplication cysts are rare malformations that exist in the alimentary tract, and the mucosa of gastric bronchogenic cyst lined by pseudostratified columnar ciliated epithelium (PCCE) is even more rare. We reviewed related literatures to depict this unique abnormality.

Case presentation:

Herein we report an abdominal mass that was found incidentally in a 52-year-old female. The biochemical test of contents revealed a high concentration of tumor markers unusually. A laparoscopic surgery was undertaken to remove the lesion. The cyst was found to originate from the stomach but did not show any anatomic communication with the stomach lumen. Pathologic examination confirmed the mucosa was lined by PCCE.

Conclusion:

The symptoms and radiologic presentations of GDC are nonspecific. It should be distinguished with other abdominal cystic masses. Surgery is advised in respective of malignancy.

Application of endoscopic ultrasound-guided-fine needle aspiration combined with cyst fluid analysis for the diagnosis of mediastinal cystic lesions

BACKGROUND

Mediastinal cystic lesions account for approximately 15-20% of all mediastinal masses and are difficult to differentiate because of similar imaging manifestation. The aim of this study was to differentiate mediastinum cystic lesions through endoscopic ultrasound-guided-fine needle aspiration (EUS-FNA) and parameters from cyst-fluid analysis.

METHODS

Over a period of eight years, 37 patients suspected with mediastinal cystic lesions were assessed. Cyst fluid was collected via EUS-FNA and further examined using cytological and biochemical techniques. Definitive diagnosis was established based on cytology, surgical pathology, and/or clinical follow-up.

RESULTS

Based on the final pathological reports or long-term follow-up, 19 patients were diagnosed with benign cysts, 14 with benign or malignant tumors, 2 with tuberculosis, 1 with an abscess, and 1 with a pancreatic pseudocyst. Computed tomography or magnetic resonance imaging mistakenly distinguished eight cases as solid masses (27.03%), but EUS revealed cystic characteristics. Carcinoembryonic antigen and lactate dehydrogenase (LDH) were evaluated from the cyst fluid obtained by EUS-FNA. There was no statistically significant difference in carcinoembryonic antigen values between benign and malignant cysts; however the average LDH value in the malignancy group was significantly higher than in the benign group.

CONCLUSION

EUS-FNA showed great potential for differentiating mediastinal lesions by combining imaging manifestation and cytological examination. The elevated LDH value from cyst fluid chemical analysis could be used as an auxiliary indicator for diagnosing malignancy.

Adult gastric duplication: an unknown condition within the spectrum of gastric submucosal lesions

BACKGROUND

Gastric duplication is an uncommon condition in adults representing only 4-8% of all gastrointestinal duplications. It develops as a cystic growth within the thick gastric wall that is surrounded by a layer of smooth muscle and lined with gastric mucosa. It is usually asymptomatic but may present with nonspecific abdominal symptoms as well as cyst-related complications such as gastrointestinal (GI) bleeding, ulceration and even pancreatitis. They are difficult to distinguish from other gastric submucosal lesions and may also mimic a gastrointestinal tumor (GIST) or mucinous cyst of the pancreas. Endoscopic ultrasound (EUS) is the most widely used diagnostic procedure and histology provides a definitive diagnosis.

CASE REPORT

We report the case of a 36-year-old female patient with a history of a "contained" perforated gastric ulcer that was managed conservatively. The patient was diagnosed with a gastric GIST which prompted a laparoscopic subtotal gastrectomy and Roux-en-Y reconstruction with a good postoperative outcome.

DISCUSSION

The definitive histological diagnosis was gastric duplication. Thus, the previous diagnosis of a "contained" perforated gastric ulcer was in fact a complication of the gastric duplication itself.

Severe Infectious Complications after Endoscopic Ultrasound-Guided Fine Needle Aspiration of Suspected Mediastinal Duplication Cysts: A Case Series

Background and Study Aims

The role of cyst cytology to diagnose mediastinal duplication cysts remains controversial. Since endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) of duplication cysts has been considered as safe so far, there are only a few case reports of infections following FNA.

Case Summary

We report a case series of all patients at our institution undergoing EUS evaluation for suspected mediastinal duplication cysts (n = 5) in the last 15 years. The mediastinal lesion in 4 patients did not feature typical EUS features for duplication cysts, wherefore we did perform EUS-guided FNA in order to rule out malignancy. In 3 out of 4 patients, a duplication cyst was confirmed. The fourth lesion turned out to be a sarcoma. All 4 patients developed severe FNA-induced cyst infection causing mediastinitis and the need for surgical debridement. Despite an immediate review of the FNA by the on-site cytopathologist with establishing the diagnosis of a duplication cyst, peri-interventional broad-spectrum antibiotics could not prevent severe infections of the lesions.

Conclusions

Given the potentially high rate of infectious complications, we advocate a very restrictive indication for diagnostic FNA in mediastinal masses. Yet, in unclear cases, FNA might be indispensable despite the potential adverse events in order to rule out hypoechogenic, mediastinal malignancy.

Gastric duplication cyst in adult: Challenge for surgeons

Gastric duplication cysts (GDCs) are uncommon developmental anomalies found primarily in children, being rarely seen in adults. Duplications can occur anywhere in the intestinal tract from the mouth to the anus. Accurate diagnosis of cysts before resection is difficult even using the most advanced imaging techniques. In this report, we present and discuss a case of GDC in a 25-year-old man treated laparoscopically. Patient admitted to our department with complaints of epigastric pain and swelling. Magnetic resonance imaging performed for accurate characterisation showed a 4 cm × 4.5 cm cystic lesion, with heterogeneous signal intensity on T2-weighted images, located in the posterior wall of the stomach. Pre-operative differential diagnosis including gastrointestinal stromal tumour (GIST) was made according to radiological findings. Patient underwent surgery and cyst resected laparoscopically. Histopathological examination suggesting duplication cyst. GDC can easily be mistaken for a GIST, and the clinician as well as radiologist must maintain a high degree of suspicion.

Efficacy and Safety of Transbronchial Needle Aspiration in Diagnosis and Treatment of Mediastinal Bronchogenic Cysts: Systematic Review of Case Reports

BACKGROUND

Although surgical resection of mediastinal bronchogenic cysts is considered the treatment of choice, there is increasing interest in minimally invasive approaches of management. The purpose of this study was to review the literature on the role of transbronchial needle aspiration (TBNA), either conventional or endobronchial ultrasound (EBUS)-guided, in the diagnosis and management of bronchogenic cysts.

METHODS

We systematically searched the PubMed and EmBase databases for studies (until July 2014) reporting TBNA of bronchogenic cysts. Data were recorded on a standard data extraction form and is presented in a descriptive manner.

RESULTS

Our search yielded 26 studies (32 patients). The median age of the patients was 43 years. Most were men (n=15), symptomatic at presentation (n=19), and had cysts in the paratracheal location (n=14). Endosonography was performed on 16 patients. The EBUS appearance of the lesion was hypoechoic and anechoic in 11 and 5 patients, respectively. Thirty-one patients underwent TBNA (conventional: 16; EBUS-guided: 15). The intent of TBNA was therapeutic in 19 patients and diagnostic or symptomatic palliation in the others. Complications were reported in 5 (16.1%) patients [infective (n=4), bradycardia (n=1)] after TBNA; there were no deaths. The median duration of follow-up was 14 months and no recurrences were detected during the follow-up period.

CONCLUSIONS

Bronchoscopy is a useful tool in the diagnosis of bronchogenic cysts, both for confirmation of the cystic nature of the lesion by EBUS and diagnosis by TBNA (preferably EBUS-guided) of the cyst fluid. Therapeutic aspiration of the cyst may be an alternative to surgery in adults with mediastinal bronchogenic cysts.

Gastrointestinal Stromal Tumor Arising From a Gastric Duplication Cyst

Gastric duplication cysts (GDC) are rarely diagnosed in adults, but previous cases have been associated with malignancy. We present a case of gastrointestinal stromal tumor (GIST) arising from a GDC in a 71-year-old woman who presented with 3 years of early satiety, anorexia, abdominal distention, and weight loss. Abdominal CT showed a 9.3 x 5.2 x 9.5-cm well-circumscribed cystic mass arising 3 cm above the gastroduodenal junction. The cyst was resected, and histopathology was consistent with GDC. Future studies are needed to clarify the malignant potential of GDC and the molecular pathways for its development.

Gastric foregut cystic developmental malformation: Case series and literature review

Foregut cystic developmental malformation (FCDM) is a very rare lesion of the alimentary tract, especially in the stomach. We discuss the concepts of gastric duplication cyst, bronchogenic cysts, and FCDM. Nomenclature has been inconsistent and confusing, but, by some definitions, gastric duplication cysts involve gastric mucosa and submucosal glands, bronchogenic cysts involve respiratory mucosa with underlying cartilage and glands, and FCDM lacks gastric mucosa or underlying glands or cartilage but has pseudostratified ciliated columnar epithelium (PCCE). We searched our departmental case files from the past 15 years and identified 12 cases of FCDM in the alimentary tract. We summarize the features of these 12 cases including a report in detail on a 52-year-old man with a submucosal cyst lined with simple PCCE and irregular and stratified circular muscle layers that merged with gastric smooth muscle bundles near the lesser curvature of the gastric cardia. A literature review of cases with this histology yielded 25 cases. We propose the term gastric-FCDM for such cases. Our own series of 12 cases confirms that preoperative recognition of the entity is infrequent and problematic. The rarity of this developmental disorder, as well as a lack of understanding of its embryologic origins, may contribute to missing the diagnosis. Not appreciating the diagnosis preoperatively can lead to an inappropriate surgical approach. In contrast, presurgical recognition of the entity will contribute to a good outcome and reduced risk of complications.

Duplication cysts: Diagnosis, management, and the role of endoscopic ultrasound

Gastrointestinal tract duplication cysts are rare congenital gastrointestinal malformation in young patients and adults. They consist of foregut duplication cysts, small bowel duplication cysts, and large bowel duplication cysts. Endoscopic ultrasound (EUS) has been widely used as a modality for the evaluation and diagnosis of duplication cysts. EUS is the diagnostic tool of choice to investigate duplication cysts since it can distinguish between solid and cystic lesions. The question of whether or not to perform EUS-fine needle aspiration (EUS-FNA) on a lesion suspected of being a duplication cyst is controversial as these lesions can become infected with significant consequences, although EUS-FNA is often required to obtain a definitive diagnosis and to rule out more ominous lesions. This manuscript will review the literature on duplication cysts throughout the body and will also focus on the role of EUS and FNA with regards to these lesions.

Non-infected and Infected Bronchogenic Cyst: The Correlation of Image Findings with Cyst Content

We hereby report a case on bronchogenic cyst which is initially non-infected, then becomes infected after bronchoscopic ultrasound (US)-guided transesophageal fine-needle aspiration (FNA). The non-infected bronchogenic cyst appears to be filled with relatively echogenic materials on US, and the aspirate is a whitish jelly-like fluid. Upon contrast-enhanced MRI of the infected bronchogenic cyst, a T1-weighted image shows low signal intensity and a T2-weighted image shows high signal intensity, with no enhancements of the cyst contents, but enhancements of the thickened cystic wall. The patient then undergo video-assisted thoracic surgery 14 days after the FNA. The cystic mass is known to be completely removed, and the aspirate is yellowish and purulent. To understand the image findings that pertain to the gross appearance of the cyst contents will help to diagnose bronchogenic cysts in the future.

Histology combined with cytology by endoscopic ultrasound-guided fine needle aspiration for the diagnosis of solid pancreatic mass and intra-abdominal lymphadenopathy

Background/Aims

Small core biopsy samples can occasionally be obtained with conventional endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA). Although most studies have focused on the cytological analysis of specimens, data regarding histological assessment is scarce. The aim of this study was to determine whether core biopsies by conventional EUS-FNA could increase the accuracy of EUS-guided sampling when combined with cytology in the absence of an on-site cytopathologist.

Methods

In the 95 consecutive patients (98 lesions) undergoing EUS-FNA of solid pancreatic masses and intra-abdominal lymphadenopathy, tissue coils from the needle were harvested for histology, and residual tissue was examined by cytology.

Results

Adequate samples were obtained by EUS-FNA cytology, histology, and combined cytology-histology in 91.8%, 65.3%, and 94.8% of patients, respectively. From the pancreas (n=67), adequate samples for histology were obtained by EUS-FNA in 68.7% of cases, compared with 58.0% from non-pancreatic cases (n=31), respectively (p>0.05). The overall sensitivity and accuracy of EUS-FNA was 78.0% and 81.6% for cytology alone, 63.4% and 69.4% for histology alone, and 84.1% and 86.7% for combined cytology-histology, respectively.

Conclusions

Combined cytology and histology analysis for diagnosing pancreatic masses and intra-abdominal lymphadenopathy may increase the diagnostic yield of conventional EUS-FNA without on-site cytology.

Foregut duplication of the stomach diagnosed by endoscopic ultrasound guided fine-needle aspiration cytology: case report and literature review

Gastric duplication cyst (GDC) with a pseudostratified columnar ciliated epithelium is an uncommon malformation supposed to originate from a respiratory diverticulum arising from the ventral foregut. Morphologic appearance of GDCs is variable, depending on the density of their contents. GDCs are often misdiagnosed as solid masses by imaging techniques, and as a consequence they may be wrongly overtreated. We report our case of a 56-year-old man with a 5 cm hypoechoic mass of the gastroesophageal junction, incidentally detected by transabdominal ultrasonography. Neither transabdominal ultrasonography nor magnetic resonance clearly outlined the features of the lesion. The patient underwent endoscopic ultrasound (EUS), which showed a hypoechoic mass arising from the fourth layer of the anterior gastric wall, just below the gastroesophageal junction. According to EUS features, a diagnosis of gastrointestinal stromal tumor was suggested. EUS-guided fine-needle aspiration cytology revealed a diagnosis of GDC with pseudostratified columnar ciliated epithelium. We therefore performed an endoscopically-assisted laparoscopic excision of the cyst.

In conclusion, whenever a subepithelial gastric mass is found in the upper part of the gastric wall, a duplication cyst, although rare, should be considered. In this case, EUS-guided fine-needle aspiration cytology could provide a cytological diagnosis useful to arrange in advance the more adequate surgical treatment.

Diagnostic endoscopic ultrasonography: Assessment of safety and prevention of complications

Endoscopic ultrasonography (EUS) has gained wide acceptance as an important, minimally invasive diagnostic tool in gastroenterology, pulmonology, visceral surgery and oncology. This review focuses on data regarding risks and complications of non-interventional diagnostic EUS and EUS-guided fine-needle biopsy (EUS-FNB). Measures to improve the safety of EUS und EUS-FNB will be discussed. Due to the specific mechanical properties of echoendoscopes in EUS, there is a low but noteworthy risk of perforation. To minimize this risk, endoscopists should be familiar with the specific features of their equipment and their patients’ specific anatomical situations (e.g., tumor stenosis, diverticula). Most diagnostic EUS complications occur during EUS-FNB. Pain, acute pancreatitis, infection and bleeding are the primary adverse effects, occurring in 1% to 2% of patients. Only a few cases of needle tract seeding and peritoneal dissemination have been reported. The mortality associated with EUS and EUS-FNB is 0.02%. The risks associated with EUS-FNB are affected by endoscopist experience and target lesion. EUS-FNB of cystic lesions is associated with an increased risk of infection and hemorrhage. Peri-interventional antibiotics are recommended to prevent cyst infection. Adequate education and training, as well consideration of contraindications, are essential to minimize the risks of EUS and EUS-FNB. Restricting EUS-FNB only to patients in whom the cytopathological results may be expected to change the course of management is the best way of reducing the number of complications.

Endobronchial ultrasound-guided transbronchial needle aspiration diagnosis of mediastinal lymph node metastasis of mucinous adenocarcinoma: arborizing stromal meshwork fragments as a diagnostic clue

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA) is a reliable and accurate method for the diagnosis of mediastinal metastases in patients with pulmonary and extrathoracic neoplasms. We report the cytopathologic findings of a case of metastatic signet-ring cell carcinoma with abundant extracellular mucin production in the mediastinal lymph nodes of a 41-year-old woman, who presented with nausea, abdominal pain, and weight loss. Imaging studies showed a renal mass, numerous lung nodules, and mediastinal and retroperitoneal lymphadenopathy. EBUS-TBNA of level 4R and 7 lymph nodes showed abundant, thick, "clean" mucus with entrapped ciliated bronchial cells, rare histiocytes, and fragments of cartilage. No neoplastic cells could be identified in Diff-Quik®-stained smears during the rapid on-site evaluation, but rare signet-ring cells were identified in the Papanicolaou-stained smears and cellblock sections. A distinctive feature of the aspirates was the presence of large branching (arborizing), "spidery" stromal fiber meshwork fragments. These stained metachromatically (magenta) with Romanowsky-type stains and cyanophilic to orangeophilic with Papanicolaou stains and showed occasional attached bland spindle cells, but had no capillary lumina or CD31-staining endothelial cells. The tumor cells were strongly and diffusely positive for CEA, CDX2, CK7, CK20, and MUC2, supporting the diagnosis of a metastatic signet-ring cell adenocarcinoma, most likely of gastrointestinal origin. We believe that the presence of the large spidery stromal fiber fragments is a useful clue to the presence of a mucinous neoplasm in EBUS-TBNA and allows the differentiation of the neoplastic mucus from contaminating endobronchial mucus.

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.

Gastric duplication cyst lined by pseudostratified columnar ciliated epithelium: a case report and literature review

Gastric duplication cyst (GDC) lined by pseudostratified columnar ciliated epithelium (PCCE) is an uncommon lesion stemming from a foregut developmental malformation. Its clinical and radiological presentation is usually nonspecific. In this study, we reported a 76-year-old man who presented with an incidentally found perigastric mass. An exploratory laparotomy revealed a non-communicating cyst below the gastroesophageal junction, measuring 4 cm×4 cm in size. Microscopically, the gastric cyst was lined merely by PCCE. Although rare, GDC lined by PCCE should be included in the differential diagnosis of gastric wall masses. Surgical intervention is warranted in patients who have clinical symptoms, or who are aged more than 50 years.

CT-guided percutaneous large-needle aspiration and bleomycin sclerotherapy for bronchogenic cyst: report of four cases

PURPOSE

Fine needle aspiration alone has been used as a treatment for bronchogenic cysts, but is subject to a high rate of recurrence. The purpose of this study was to review our experience with computed tomography (CT)-guided percutaneous large-needle aspiration and bleomycin sclerotherapy of bronchogenic cysts in four patients.

MATERIALS AND METHODS

Four patients with bronchogenic cysts at subcarinal (n = 1), paraspinal (n = 1), or intrapulmonary (n = 2) sites were treated at two medical centers with percutaneous transthoracic aspiration with a 17.5-gauge needle and sclerotherapy with use of bleomycin as the sclerosant agent. Clinical symptoms were seen in three of the four patients: recurrent cough in two and recurrent chest discomfort and palpitation in one. CT was used to guide the procedures. After sclerotherapy, the sizes of ablated cysts were followed by CT.

RESULTS

At a median follow-up of 10 months (range, 6-14 months), all three patients with symptoms had symptomatic relief and all four patients showed a nearly complete regression of bronchogenic cyst on follow-up CT. No recurrence was encountered. Minor complications included a small asymptomatic pneumothorax at the end of the procedure in one patient and a mild fever (38.0 degrees C-38.5 degrees C) on the first day after sclerotherapy in one patient, which resolved spontaneously without treatment. No major complications occurred.

CONCLUSIONS

CT-guided percutaneous treatment of bronchogenic cysts with large-needle aspiration and bleomycin sclerotherapy was safe and effective in this limited series. Further investigation of this technique is warranted.

Ciliated foregut cyst of the pancreas: preoperative diagnosis using endoscopic ultrasound guided fine needle aspiration cytology--a case report with a review of the literature

A 51-year-old male presented with a 4-month history of abdominal pain, decreased appetite, and postprandial bloating. A CT scan showed a solitary, 5.3 x 4.4 cm, cystic lesion in the body/tail of the pancreas. Endoscopic retrograde cholangiopancreatography did not show communication between the pancreatic duct and the cystic lesion. Endoscopic ultrasound (EUS) examination revealed a 6.9 x 2.4 cm cystic lesion in the body/tail region of the pancreas without septae or solid components. The pancreatic parenchyma, pancreatic duct, and common bile duct were unremarkable. EUS-guided fine needle aspiration (EUS-FNA) was performed using a 22-gauge EchotipTM needle. Only a few drops of viscous fluid could be aspirated. Papanicolaou-stained direct smears and SurePath (Autocyte) preparations were evaluated. The direct smears were hypocellular; however, the concentration method producing liquid-based cytology preparation showed detached ciliary tufts (degenerated debris with ciliated cellular fragments of cell tops without nuclei) and occasional intact ciliated cells consistent with a ciliated foregut cyst. Although benign, the cyst was resected to alleviate the symptoms. The surgical pathology confirmed the benign preoperative interpretation of the ciliated foregut cyst. To the best of our knowledge, this is the first case of pancreatic ciliated foregut cyst reported to be diagnosed preoperatively by EUS-FNA. For a proper preoperative cytologic diagnosis, the needle rinses should be processed adequately. Otherwise, these hypocellular specimens with mucin may be misinterpreted as mucinous cystic lesions.

Role of EUS and EUS-guided FNA in the diagnosis of rectal implantation cyst at an anastomosis site after a previous low anterior resection for a rectal cancer without evidence of cancer recurrence

BACKGROUND

Rectal implantation cysts occurring at an anastomosis site after a low anterior resection for rectal cancer need to be distinguished from locally recurrent rectal cancer.

OBJECTIVE

Our purpose was to evaluate the role of EUS and EUS-FNA in the diagnosis of rectal implantation cyst.

DESIGN

Case series.

PATIENTS

A review of medical records identified 3 men and 1 woman who were diagnosed with rectal implantation cyst by EUS and EUS-FNA.

RESULTS

All 4 cases had undergone a low anterior resection with the double-stapling technique for a rectal cancer from 12 to 67 months (median 33.8 months) earlier. Follow-up colonoscopy revealed a rectal submucosal tumor at an anastomosis site. EUS revealed cystic lesions with heterogeneous wall thickness from the third layer or the fourth layer to the surroundings. EUS-FNA revealed mucin that contained a few inflammatory cells and no malignant cells in any of the patients. From the findings of EUS and EUS-FNA, all patients were diagnosed with rectal implantation cyst, thus avoiding surgery.

LIMITATION

Small number of patients.

CONCLUSIONS

EUS and EUS-FNA are useful in the diagnosis of rectal implantation cyst and the avoidance of unnecessary radical surgery.

Ciliated foregut cyst of pancreas: cytologic findings on endoscopic ultrasound-guided fine-needle aspiration

The cytologic findings of a ciliated foregut cyst of the pancreas diagnosed by endoscopic ultrasound-guided fine-needle aspiration (FNA) are described. Cytologic features of ciliated foregut cysts include the presence of ciliated columnar cells and detached ciliary tufts in a cystic fluid background with amorphous debris and rare macrophages. These cytologic findings are clearly distinct from those of cystic mucinous neoplasms and other pancreatic cysts with which the ciliated foregut cyst may be confused. To the best of our knowledge, this is the first case reporting the cytologic findings of a pancreatic ciliated foregut cyst sampled by endoscopic ultrasound-guided FNA. We believe that the distinctive and characteristic cytologic features can allow a preoperative cytologic diagnosis of this highly unusual pancreatic cystic lesion.

Diagnosis of foregut and tailgut cysts by endosonographically guided fine-needle aspiration

Foregut, hindgut, and tailgut cysts are uncommon developmental anomalies. Clinical and radiological diagnosis can present many challenges, especially in adult patients or when the lesions are in unique locations. Thus, diagnosis has traditionally been provided upon surgical resection. We describe the diagnoses of a gastric foregut cyst and a retrorectal tailgut cyst by endosonographically guided fine-needle aspiration in two adults. The common cytologic features of the specimens are ciliated epithelial cells, proteinaceous material with degenerated debris, histiocytes, and benign appearing epithelium of squamous and/or gastrointestinal type that lack cytologic atypia. The identification of ciliated columnar cells is the key finding. Cytologic diagnosis via endosonographically guided fine-needle aspiration of foregut/hindgut cyst is accurate and less traumatic than surgical biopsies.

Advantage of EUS Trucut biopsy combined with fine-needle aspiration without immediate on-site cytopathologic examination

BACKGROUND

Endoscopic ultrasonographically guided fine-needle aspiration (EUS-FNA) is a safe and accurate method for obtaining diagnostic material from lesions within and immediately adjacent to the upper GI tract.

OBJECTIVE

To determine whether EUS Trucut biopsy (EUS-TCB) (Quickcore, Wilson-Cook, Winstom Salem, NC) can increase the accuracy of EUS-guided tissue sampling when combined with FNA when no cytopathologist is present.

DESIGN

Retrospective case review.

SETTING

University-based referral practice.

PATIENTS

All patients who had lesions that were accessible through the esophagus or stomach and that were greater than 20 mm and amenable to Trucut biopsy were included.

INTERVENTIONS

A total of 41 patients underwent both EUS-FNA and TCB with a separate pathologist evaluating each specimen.

MAIN OUTCOME MEASUREMENTS

The diagnostic performance of FNA, TCB, and its combination were compared.

RESULTS

The overall accuracy in our series was as follows: FNA, 76%; TCB, 76% (P not significant); and combination of FNA and TCB, 95% (P = .007). In the 26 patients with malignant diagnoses, the accuracy of combination was 100% versus 77% for FNA (P = .03). The median number of passes with the FNA and TCB was 4.4 (range 2-8) and 2.8 (range 2-5), respectively. One patient in the series had fever and chest pain after EUS biopsy.

LIMITATIONS

Retrospective study.

CONCLUSION

In our series EUS-TCB accuracy was equal to FNA when no on-site cytopathologist is present. TCB was helpful in the diagnosis of pancreatic masses, gastric submucosal lesions, lymphoma, and necrotic tumors. A 100% accuracy of FNA + TCB was seen in patients with malignant diseases and in patients who had failed or been refused biopsy by other modalities in the past. More data are needed before the exact role of TCB in the absence of on-site cytopathology can be accurately defined.

Review of endoscopic ultrasound-guided fine-needle aspiration cytology

This review, based on the Hennepin County Medical Center experience and review of the literature, vastly covers the up-to-date role of endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (FNA) in evaluating tumorous lesions of the gastrointestinal tract and adjacent organs. Emphasis is given to the tumoral and nodal staging of esophageal, pulmonary, and pancreatic cancer. This review also discusses technical, pathological, and gastroenterologic aspects and the role of the pathologist and endosonographer in the evaluation of these lesions, as well as the corresponding FNA cytology and differential diagnosis.