1. Unexplained mediastinal and abdominal lymphadenopathy
Jason R Phillips, MD

2. Case
HPI: 42 y/o F referred to GI for an abnormal CT of the chest and abdomen.
Presented 2 months ago to PCP with URI symptoms – cough, low grade fever, and marked fatigue
Fatigue symptoms persisted for > 1 month

3. Case PMH/PSH: none Medications: BCP NKDA SH: Denies tobacco, EtOH
FH: Mother died of Hodgkin’s disease at age 64

4. Case Physical exam: VSS, afebrile Gen: NAD, overweight
HEENT: PERRL, EOMI, nl oropharynx
Neck: no LAD, FROM
Lungs: CTA – no crackles or wheezes
CV: RRR
Abd: + BS, mild epigastric tenderness, no hepatosplenomegaly
Ext: No edema
Neuro exam: normal

5. Case Workup initiated Labs: normal CBC, electrolytes, TSH, urinalysis
CXR: prominent mediastinum and recommended CT for further evaluation

6. Case
CT Chest and abdomen: multiple, enlarged (>1.5 cm) mediastinal, celiac, and periaortic abdominal lymphadenopathy
No masses or nodules were seen in the lungs, pancreas, liver, spleen, or pelvis

7. DDX: internal lymphadenopathy
Reactive changes from recent infection/inflammation
Infectious – viral, bacterial, fungal, TB
Neoplasm – metastatic, lymphoma, leukemia
Connective tissue disease (SLE, RA, …)
Lymphoproliferative diseases
Sarcoidosis
Other: amyloidosis, histiocystosis, Castleman’s disease,…

8. Case
Pt was very concerned with the possibility that the nodes could represent lymphoma since her mother recently died from HD
Further serologic evaluation:
Negative PPD, ANA, RA, HIV
Referred for mediastinal lymph node biopsy by EUS

12. Case FNA: 4 passes performed in the presence of a cytopathologist
Results: noncasseating granulomas consistent with sarcoidosis
Patient followed up with her PCP and was asymptomatic.

14. Endoscopic Ultrasound
Experimental EUS first performed 1980 as a diagnostic tool
EUS plays important role
Localized staging (tumor size, nodes, and invasion into critical structures for surgery)
Esophagus
Stomach
Pancreas
Rectum
Evaluation of subepithelial masses

15. Endoscopic Ultrasound
EUS FNA developed in the 1990s
Expanding role for EUS – tissue sampling
Peri-intestinal masses and lymph nodes (esophagus, mediastinum, stomach, pancreas, rectum, bile duct)

16. Endoscopic Ultrasound
Radial scanning echoendoscope
Allows 360 degree views of the GI tract
Multiple frequencies allow for enhancement of echogenic contrast in tissues
Curvilinear array echoendoscope
100 degree sector scan
Allows for FNA sampling

19. Advantages of EUS
Ability to place the ultrasound transducer on the tissue of interest and obtain high resolution imaging between tissue planes
Ability to sample tissue under direct visualization

23. Advantages of EUS: Subepithelial masses
Defines the echogenic histologic layer of origin for subepithelial masses
Examples,
Leiomyomas Lipoma
GIST Carcinoid
Retention cyst Pancreatic rest
Fibroma Granular cell tumor

25. Advantages of EUS: Cancer staging
Defines T stage for malignancies by defining involvement to histologic layers
Defines N staging
Helps determine resectability
Esophageal, gastric, pancreatic, and rectal cancers

27. EUS FNA

28. EUS and Mediastinal Nodes
Esophagus provides a window for biopsy of posterior mediastinal nodes
Subcarinal
Aortopulmonic
Periesophageal
Important for tissue sampling in LAD of unknown cause and staging lung cancer (particularly non-small cell lung cancer)

29. EUS and Mediastinal Nodes

30. EUS FNA of Mediastinal Nodes
CT vs EUS with FNA in pts (n=52) w NSCLC and mediastinal nodes who went to surgery
CT: accuracy of 49%
EUS: accuracy of 84%
EUS with FNA: accuracy of 96%
Results prompted a change in management in 95% of patients
Gress et al …Ann Int Med 127: 604, 1997

31. EUS FNA of Mediastinal Nodes
EUS FNA of mediastinal nodes of unknown etiology
Known final diagnosis from surgery, autopsy, mediastinoscopy, or long term follow-up
EUS FNA established a tissue diagnosis in 90% of pts

32. EUS FNA of Mediastinal Nodes
Diagnoses included: NSCLC, lymphoma, adenocarcinoma of unknown primary, breast cancer, ovarian cancer, inflammatory/reactive, histoplasmosis, and sarcoidosis
EUS FNA influenced subsequent evaluation and therapy in 87% patients
Catalano et al… Gastrointestinal Endoscopy 2002, 55:863-9

33. EUS FNA of Mediastinal Nodes
Retrospective study of 49 pts w mediastinal masses of unknown etiology
EUS FNA  malignant process 49%, benign process 45%, and nondiagnostic in 6%
Accurate diagnosis was made in 94% of cases
Devereaux et al…Gastrointestinal Endoscopy 2002, 56:

34. EUS FNA and Sarcoidosis
Case series
10 pts with intrabdominal LAD but without mediastinal LAD found incidentally on CT
EUS FNA revealed noncaseating granulomas
Moskowitz et al…Gastrointestinal Endoscopy 2002, 56(4): S175

35. EUS FNA safety profile
Review of 900 EUS FNA of solid masses  no complications were seen
Gastrointest Endosc 2001 Apr;53(4):470-4
Gut 1999 May;44(5):720-6
Gastroenterology 1997 Apr;112(4):

36. EUS FNA safety profile
Multicenter trial 554 consecutive mass/LN EUS FNA
5 complications were reported
Perforation in 2 patients (0.4%)
Febrile illness in 2 patients with cystic lesions (0.4%)
Bleeding in one patient (into a pseudocyst) (0.2%)
Gastroenterology 1997 Apr;112(4):

37. EUS FNA safety profile Rare complications
Acute pancreatitis (pancreatic cysts/masses) < 1%
Case reports:
Pneumoperitoneum
Bacteremia
Portal vein thrombosis

38. Bibliography
Endoscopic Ultrasound-Guided Fine Needle Aspiration is Superior to Lymph Node Echofeatures: A Prospective Evaluation of Mediastinal and Peri-Intestinal Lymphadenopathy. Chen VK; Eloubeidi MA Am J Gastroenterol 2004 Apr;99(4):
Endoscopic ultrasonography, fine-needle aspiration biopsy guided by endoscopic ultrasonography, and computed tomography in the preoperative staging of non-small-cell lung cancer: a comparison study. Gress FG et al; Ann Intern Med 1997 Oct 15;127(8 Pt 1):
Endoscopic ultrasound with fine-needle aspiration in the diagnosis and staging of lung cancer. Silvestri GA et al. Ann Thorac Surg 1996 May;61(5):1441-5; discussion
Mediastinal lymphadenopathy in patients with or without previous malignancy: EUS-FNA-based differential cytodiagnosis in 153 patients. Fritscher-Ravens A et al…Am J Gastroenterol 2000 Sep;95(9):

39. Bibliography
Distant lymph node metastases in esophageal cancer: impact of endoscopic ultrasound-guided biopsy. Giovannini M et al…; Endoscopy 1999 Sep;31(7):536-40
Endoscopic ultrasound-guided fine-needle aspiration biopsy using linear array and radial scanning endosonography. Gress FG et al; Gastrointest Endosc 1997 Mar;45(3):243-50
Fine-needle aspiration cytology guided by endoscopic ultrasonography: results in 141 patients. Giovannini M et al; Endoscopy 1995 Feb;27(2):171-7.
Transesophageal biopsy of mediastinal and pulmonary tumors by means of endoscopic ultrasound guidance. Hunerbein M et al; J Thorac Cardiovasc Surg 1998 Oct;116(4):554-9.
An early comparison between endoscopic ultrasound-guided fine-needle aspiration and mediastinoscopy for diagnosis of mediastinal malignancy. Serna DL et al; Am Surg 1998 Oct;64(10):

40. Bibliography
Evaluation of mediastinal lymphadenopathy with endoscopic US-guided fine-needle aspiration biopsy. Wiersema MJ et al; Radiology 2001 Apr;219(1):252-7
A descriptive analysis of EUS-FNA for mediastinal lymphadenopathy: an emphasis on clinical impact and false negative results. Hernandez LV et al; Am J Gastroenterol 2004 Feb;99(2):
The clinical utility of endoscopic ultrasound-guided fine-needle aspiration biopsy for diagnosing intra-abdominal sarcoidosis. Yitzchak Moskowitz Gastrointestinal Endoscopy 2002, 56(4), S175
EUS-guided fine-needle aspiration combined with flow cytometry and immunocytochemistry in the diagnosis of lymphoma. Afonso Ribeiro et al; Gastrointest Endosc 2001;53:485-91
Clinical utility of EUS-guided fine-needle aspiration of mediastinal masses in the absence of known pulmonary malignancy. Benedict M. Devereaux et al; Gastrointest Endosc 2002;56:

41. Bibliography
EUS-guided fine needle aspiration in mediastinal lymphadenopathy of unknown etiology Marc F. Catalano et al; Gastrointest Endosc 2002;55:863-9.

42. Questions?