EUS-FNA Karolinska experiences

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1 EUS-FNA Karolinska experiences Karin von Sivers Diagnostic Radiology Vitali Sviatoha Pathology and Cytology Edneia Tani Pathology and Cytology Karolinska University Hospital - Solna Stockholm - Sweden

2 Use of Endoscopic ultrasound guided FNA Difficult accessible intrathoracic, intraabdominal and gastrointestinal lesions. Aspiration biopsy during endoscopic procedure. Alternative for open surgical, laparascopical biopsy.

3 Advantages of Endoscopic ultrasound guided FNA: Aspirates from difficult accessible lesions: - mediastinal lymph nodes / tumors, lung tumors. - esophageal wall - ventricular wall - gallbladder, liver - pancreas, spleen, left adrenal gland - intraabdominal cavity - colon Enough material for morphology and ancillary techniques. Less traumatic than surgical biopsy Cheaper than surgical biopsy Visible US structure of the lesion, adjacent structures and vascularisation (Doppler).

4 Disadvantages of Endoscopic ultrasound guided FNA: Experienced personal needed. More expensive than usual FNA or USguided FNA. Time consuming procedure comparing to usual FNA or US-guided FNA. (ca 30 min at Karolinska Hospital).

5 EUS-FNAB Retrospective study 337 patients male : 163 female Age: 2-86 year Supradiafragmatic 181 Infradiafragmatic 156

6 EUS-FNAB Outpatient examination No coagulation status Fasting 4 hours Pharyngeal anestesia with spray Sedation- Midazolam 1mg/ml, 2-5 mg i.v. (Ketogan 2.5mg, 1mg/ml i.v.) Time required aprox 30 min

7 EUS- linear scanning Endoscopic video image EUS - radial scanning

8 EUS-INTERVENTION Sector/Linear Olympus GF-ULT 160 Power Doppler

9 EUS-FNAB Olympus 0,7 mm 22G Cook 0,5 mm 25G Biopsy channel 3.8mm

10 Smear Cell suspension

11 Cytopathologist assistance on site Clinical information Smear preparation Cell suspension Quick staining Microscopy

12 EUS-FNAC smears cell susp MGG, Pap Mib-1, TTF-1, CDX2 ER, PR, AR cytospin (immuno, FISH) flow cytometry gene rearrangement cell block (coagulated material) bacteriology

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14 EUS-FNAC: 337 patients immuno flow 156 infradiafragmatic supradiafragmatic (40%) 9

15 EU-FNA: 337 cases CYTOLOGIC DIAGNOSIS: Benign 151 (5 false negative) Malignant 153 Suspicious 13 Non diagnostic 20

16 False negative : 5 cases Mucinous cystic pancreas tumor- ca in situ Pancreas cancer Esofagus cancer recurrence Sclerosing esofagus ca Cardia cancer

17 Supradiafragmatic: 181 cases Mediastinal lymph nodes 145 Esophagus 15 Lung 12 Pleura 3 Paravertebral lesion 3 Intrathoracal goiter 2 Paraesophageal 1

18 Infradiafragmatic: 156 cases Pancreas 92 Stomach 27 Abdominal cavity 9 Lymph node 7 Adrenal 6 Duodenum 3 Mesenterium 2 Spleen 1 Other retroperitoneal 8

19 Supradiafragmatic EUS-FNA: 181 cases Malignant 84 cases Benign 85 cases Suspicious 9 cases Non diagnostic 3 cases Total: 181 cases

20 Supradiafragmatic FNA: 181 cases (malignant: 84 cases) Mediastinal nodes 18 adeno ca 14 poorly diff ca 6 SCLCA 6 squamous ca 5 neuroendocrine ca 2 melanoma 2 renal cell ca 1 prostate ca 1 Merkel cell ca 1 breast 1 adrenal 1 sarcoma Lung 5 adeno ca 3 poorly diff ca 2 SCLCA 1 squamous ca 3 metastasis Pleura 3 mesothelioma Esophagus 1 adeno ca Mediastinum 1 sarcoma

21 CK7 CK20 adenocarcinoma TTF-1

22 Small cell lungcancer

23 MGGiemsa cytokeratin

24 Supradiafragmatic FNA: 181 cases (Benign: 85 cases) Benign diagnosis: 29 benign lymph node 24 granulomatous lymphadenitis 2 granular cell tumor esophagus 2 intrathoracal goiter 2 schwannoma

25 Recurrence paresis. Malignancy?

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29 Infradiafragmatic EUS-FNA: 156 cases Malignant 69 cases Benign 66 cases Suspicious 10 cases Non diagnostic 11 cases Total: 156 cases

30 Infradiafragmatic EUS-FNA: 156 cases Malignant:69 cases Benign: 66 cases Adenocarcinoma 38 pancreas 3 lymph node 2 intra abdomnal 1 gastric GIST 9 gastric Metastasis 5 adrenal (lung ca) 2 pancreas 1 spleen (melanoma Neuroendocrine tumor 3 pancreas 3 gastric Lymphoma 3 lymph node Sarcoma 1 retroperitoneal Benign cyst 20 pancreas

31 CD117 GIST

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33 CK HMB45 S100

34 EU-FNA: 337 cases Malignant 153 Benign 151 Suspicious 13 (3.8%) Non diagnostic 20 (5.9%) Total 337

35 EUS-FNAC: 337 cases year nr infradiaf supradiaf non diag susp (16%) (17%) 1(3.4%) (5%) 2(3.5%) (1.6%) 3(4.8%) (6%) 4(3.5%) (3%) 3(4.9%) total (5.9%) 13 (3.8%)

36 Endoscopic ultrasound guided FNA Conclusions: - Is a reliable diagnostic method for difficult accessible intraabdominal and thoracic lesions. - Cooperation between endoscopist and cytopatologist is important. - Correct care of the sample for morphology and different ancillary techniques - On site assessment of sample with quick staining and microscopy

37 Final message For endoscopists: look for experienced cytopathologists! For cytopathologists: work in cooperation with skillfull endoscopists!

38 Thank you for your attention!