Clinical utility of endoscopic ultrasound and endscopic ultrasound-guided fine needle aspiration in retroperitoneal neoplasms

Abdominal Inflammatory Myofibroblastic Tumour Presenting as a Pancreatic Mass: A Case Report

An abdominal inflammatory myofibroblastic tumor (AIMT), is a rare benign tumor composed of inflammatory and other mesenchymal cells. It can affect the entire body, predominantly in children and young adults. The diagnosis is challenging considering the wide clinical presentation and can often be mistaken for malignant tumors. We report a rare case of a 46-year-old female patient, who presented with intermittent abdominal pain weight loss, and an abdominal palpable mass. Abdominal ultrasound found a well-defined 18 cm, rounded mass, with solid and cystic components. Abdominal CT demonstrated a well-defined, hypodense, retro gastric mass of 20 cm, with thickened wall and heterogenous enhancement. The mass had contact with the pancreatic tail, transverse colon, spleen, left kidney pedicles, abdominal aorta, superior mesenteric vein, and mesaraic trunk with no invasion signs. The mass was initially thought to be pancreatic cancer, but given the large size, other diagnoses like sarcoma, lymphoma, or abdominal hydatid cyst were suggested. Endoscopic ultrasound found a rounded retro gastric mass of 18/12 cm, with a thickened wall and well-limited calcifications. The content was both cystic and solid with mobile vegetations, with no visible Doppler flow. The mass had contact with the body and tail of the pancreas, spleen hilum, the upper pole of the spleen, and the hepatic pedicle behind, with no invasion sign. After a multidisciplinary team meeting, a decision was taken to perform surgical resection with mass resection, distal splenopancreatectomy, and transverse and sigmoid colectomy. Pathological and immunostaining results were consistent with inflammatory pseudotumor. The postoperative recovery was uncomplicated. The patient remains asymptomatic with no obvious signs of metastasis or recurrence. AIMT represents a reel diagnostic challenge. Clinical symptoms are unspecific. Radiological and endoscopic features can often be mistaken for malignant tumors. Surgical management remains to be the best therapeutic option. We report a rare case of AIMT treated by surgery with complete resection. We suggested a long-term follow-up given the local recurrence risk.

Two Needle Passes Achieve Similar Diagnostic Yield Compared to Three Passes Regarding Diagnosis of Solid Pancreatic Lesions in Endoscopic Ultrasound-Guided Fine Needle Aspiration

Current guidelines advocate 3–4 passes with a fine-needle aspiration (FNA) to achieve high rates of diagnostic samples for malignancy when performing endoscopic ultrasound (EUS)-guided sampling of solid pancreatic lesions, in the absence of on-site cytologic evaluation. The aim of this study is to compare 2 vs. 3 needle passes in EUS-FNA for solid pancreatic lesions in terms of incremental diagnostic yield and to identify factors associated with the procedure’s outcome. In this retrospective study, 2 passes of EUS-FNA were found to have similar diagnostic yield compared to 3 passes for the diagnosis of solid pancreatic masses, suggesting that there might be no significant incremental tissue yield when 3 passes are performed.

[Retroperitoneal leiomyoma: a case report]

Retroperitoneal leiomyoma is a rare benign tumor of the retroperitoneum. We report a clinical case of a 43-year-old patient, who suffered from back pain and weight loss. Imaging revealed a retroperitoneal mass, then the patient had a total excision of the tumor. Histological examination of the surgical specimen concluded to retroperitoneal leiomyoma. The evolution was good without recurrence after 12 months.

Cytotechnologists and on-site evaluation of adequacy

While fine needle aspiration (FNA) is certainly not a new biopsy technique, recent developments in advanced imaging techniques, molecular testing, and targeted therapies have coincided with a rapid increase in the number of FNA procedures being performed. Concurrently, the demand for on-site evaluation of adequacy (OSEA) has also increased, outstripping the capacity of available cytopathologists at some institutions. Among the several alternatives to cytopathologist-performed OSEA, cytotechnologist-attended OSEA stands out because it preserves the representation of the pathology service at the time of the procedure. Herein, we review the current literature about OSEA and the necessity of cytotechnologists to expand access of this useful pathology service to a broader patient population. We also examine how cytotechnologists are likely to fit into the emerging practice of telecytology.

Obstructive jaundice as an initial manifestation of non-hodgkin lymphoma: treatment dilemma and high mortality

Introduction. Non Hodgkin lymphoma (NHL) presenting with obstructive jaundice is a rare occurrence. Because of rarity of combination, it is seldom considered in differential diagnosis of patients presenting with obstructive jaundice. It is considered treatable due to the chemosensitive nature of the disease and the recent advances in chemotherapy. Case Series. We present a case series of 2 patients with NHL presenting with obstructive jaundice as an initial manifestation. Both patients presented with obstructive jaundice and were diagnosed by CT guided liver biopsy. One patient died of sepsis and multiorgan failure before initiating chemotherapy and the second patient did not choose to undergo chemotherapy. Conclusion. Biliary obstruction is a sign of poor prognosis. The diagnosis of NHL needs to be considered in patients presenting with biliary obstruction. It can be associated with high mortality and poses treatment dilemma.

Pelvic retroperitoneal leiomyoma

Primary retroperitoneal leiomyomas are a rare and unusual differential diagnosis in the acute abdomen. A 26-year-old woman presented with chronic constipation and acute abdominal pain. The diagnostic workup included contrast computer tomography, transabdominal ultrasonography, and colonoscopy that revealed an 8-cm homogeneous pelvic tumor with rectal compression. Retroperitoneal leiomyoma was suspected on imaging studies and finally confirmed after tumor excision and immunohistochemical staining.

Non-Hodgkin lymphoma as a cause of obstructive jaundice with simultaneous extrahepatic portal vein obstruction: A case report

Non-Hodgkin lymphoma is a rare cause of biliary obstruction. To the best of our knowledge, non-Hodgkin lymphoma in the peripancreatic region causing obstructive jaundice with simultaneous portal vein (PV) invasion has not yet been reported. We present a 50-year-old patient with obstructive jaundice whose extrahepatic portal vein was obstructed by the invasion of a peripancreatic non-Hodgkin lymphoma. The patient denied any other symptoms such as recurrent fever, night sweat and loss of body weight. Computed tomography (CT) revealed a 10 cm mass in the retroperitoneal space behind the head of the pancreas causing obstruction of the distal bile duct and the PV. A pylorus-preserving pancreaticoduodenectomy combined with a PV resection was performed. The PV was reconstructed using an autologous right internal jugular vein graft. The resected specimen showed endoluminal invasion of both the bile duct and the PV. Histological examination showed the mass consisting of diffuse sheets of large malignant lymphoid cells. These cells were positive for CD20 and CD79a, partially positive for CD10, and negative for CD3, CD4, CD5, CD8 and CD30. The pathologic diagnosis was diffuse large B-cell type non-Hodgkin lymphoma and the patient was transferred to the Department of Hematology and Oncology for chemotherapy. He received four cycles of combined chemotherapy including cyclophosphamide, doxorubicin, vincristine and prednisone plus rituximab, and three cycles of intrathecal chemoprophylaxis including methotrexate, cytosine arabinoside and prednisone. The patient is alive with no evidence of the disease for 7 mo after operation and will receive additional courses of chemotherapy.

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.

EUS-guided fine needle aspiration of idiopathic abdominal masses

BACKGROUND

EUS-guided fine needle aspiration (EUS-FNA) has significantly increased the diagnostic capability of EUS. FNA can also be helpful in the diagnosis of non-GI disorders. The role of EUS-FNA in the diagnosis of idiopathic abdominal masses has not been determined. This study evaluated the diagnostic accuracy of EUS-FNA of abdominal masses of unknown cause and its impact on subsequent evaluation and therapy.

METHODS

Thirty-four patients from 5 tertiary referral centers (21 women, 13 men; mean age 54 years, range 27-72 years) with idiopathic abdominal masses underwent EUS-FNA. Presenting symptoms included the following: pain (29 patients), weight loss (15), altered bowel habits (7), nausea/vomiting (6), abnormal liver function tests (4), palpable mass (4), and urinary retention (1). Four patients had a history of intra-abdominal cancer (2 cervical, 1 ovarian, 1 colon). A final diagnosis by EUS-FNA, surgery, autopsy, or long-term follow-up was available in all patients. Abdominal masses were classified into 3 disease categories: infectious, benign/inflammatory, and malignant.

RESULTS

Final diagnosis included infectious (5), benign/inflammatory (6), and malignant (23) abdominal mass. Overall, EUS-FNA established a tissue diagnosis in 29 of 34 patients (85%) in all 3 categories (infectious, 80%; benign/inflammatory, 67%; malignant, 91%). EUS-FNA was instrumental in directing subsequent evaluation in 29 patients (85%) and therapy in 26 (77%). The number of fine needle passes for adequate tissue sampling was lower for nonmalignant (2.2-3.2) versus malignant diseases (4.6). One complication occurred (perirectal abscess) and was treated successfully with antibiotics.

CONCLUSIONS

EUS-FNA of idiopathic abdominal masses is safe and accurate and helps to guide subsequent evaluation and therapy in the majority of patients. The most common and promising area seems to be EUS-FNA of malignant abdominal masses. Transluminal EUS-FNA provides minimally invasive tissue sampling and obviates the need for exploratory laparotomy.

Cytologic diagnosis of gastrointestinal stromal tumor with emphasis on the differential diagnosis with leiomyosarcoma

BACKGROUND

Gastrointestinal stromal tumor (GIST) has only recently been distinguished histologically and immunochemically from morphologically similar neoplasms of the abdomen.

METHODS

The authors reviewed 15 cytologic cases of GIST (14 fine-needle aspiration [FNA] specimens and 1 peritoneal fluid specimen) and compared them with 23 cases of leiomyosarcoma (LMS) arising in the abdomen or pelvis (all FNAs). Immunochemistry (IC) was performed on both the cytologic and subsequent tissue specimens if sufficient specimen was available.

RESULTS

Cytologic samples of GISTs typically showed irregularly outlined clusters of uniform spindle cells that were spread easily without crush artifact. The cells had wispy cytoplasm with long, delicate, filamentous extensions (13 cases; 87%). A prominent vascular pattern was common (9 cases; 60%); pleomorphism (1 case; 7%) was uncommon. The LMSs showed three-dimensional, tightly cohesive, sharply marginated syncytia of spindle cells, often with nuclear crush artifact. The cytoplasm/stroma had a distinct wiry, refractile appearance (21 cases; 91%); delicate filamentous cytoplasmic extensions (5 cases; 22%) and prominent vessels (3 cases; 13%) were less common. LMSs more commonly exhibited pleomorphism (14 cases; 61%). Epithelioid cytomorphology, mitoses, and necrosis occasionally were observed in both tumor types. IC for c-kit (on cytologic material) was positive in 10 of 10 cases of GIST (usually diffuse and strong) and 2 of 19 cases of LMS (focal). CD34 positivity favored GIST (4 of 9 cases) over LMS (1 of 19 cases). Smooth muscle actin was positive in 20 of 20 LMSs (strong and diffuse) and 6 of 10 GISTs (usually focal). Desmin was positive in 12 of 20 LMSs and was only focally positive in 1 of 11 GISTs. Correlation of IC results was excellent between cytologic and tissue specimens.

CONCLUSIONS

Delicate cytoplasmic processes; a prominent vascular pattern; a lack of nuclear pleomorphism; and a c-kit-positive, desmin-negative immunoprofile are characteristic features of GIST and help distinguish these tumors from LMS in cytologic specimens.