1. Isam A. Eltoum, Section Head, Cytopathology, UAB
Endoscopic Ultrasound Guided Fine Needle Aspiration (EUS-FNA): New Frontiers in Diagnostic Cytopathology
Isam A. Eltoum,
Section Head, Cytopathology, UAB

2. GI tube
Lymph nodes
Wall lesions
Pancreas
Liver
Spleen
Adrenal

3. EUS-FNA: Disruptive Technology
Fine needle aspiration
Flexible endoscope
Ultrasound
Eltoum et al Arch Pathol Lab Med136, April 2012

5. Eltoum et al Arch Pathol Lab Med136, April 2012

6. Gastrointestinal Lesions

7. Indications
Organ site to be aspirated
Algorithmic approach
Pitfalls
Performance of EUS-FNA

8. Indications for EUS Diagnosis of intra- and extra-wall lesions
Origin of lesion at sub anatomical level
Measurement of lesion size
Tumor and nodal staging
Evaluation of thickened mucosa
Histological/cytological nature of the lesion

9. Sites Organs
Esophagus
Stomach
Duodenum
Rectosigmoid
Anal region

10. http://www. ddc. musc. edu/ddc_pro/pro_development/atlases/EUS/index

11. Normal Esophageal Epithelium

12. http://www. ddc. musc. edu/ddc_pro/pro_development/atlases/EUS/index

13. Normal Gastric Epithelium

14. Normal Gastric Epithelium

15. Normal Intestinal epithelium

16. Normal lamina propria

17. Normal Muscularis propria

18. Normal Intestinal Epithelium

19. http://www. ddc. musc. edu/ddc_pro/pro_development/atlases/EUS/index

20. Rectal epithelium

21. Seminal vesicle

22. Diagnostic Algorithm Is the specimen satisfactory? What type of cells?
Large polygonal (epithelial)
Epitheliod
Spindle cells
Small round cell
Mixed
Background?

23. Diagnostic Algorithm
Cystic lesions

24. Diagnostic Algorithm Predominantly Epithelial pattern: Squamous
Glandular
Neuroendocrine
Poorly differentiated

25. Diagnostic Algorithm Predominantly Epithelioid Cell Pattern:
Glomus tumor
GIST
Smooth muscle tumors
Neuroendocrine tumors

26. Esophageal Carcinoma

27. Squamous Cell Carcinoma

28. Gastric Cancer

29. Adenocarcinoma

30. Ectopic Pancreas

31. Rectal Carcinoma

32. Rectal carcinoma

33. Rectal carcinoma

34. Peri-rectal metastasis

35. Carcinoid

36. Carcinoid

37. Carcinoid

38. Another Carcinoid

39. Diagnostic Algorithm Spindle cell pattern: GIST Smooth muscle tumors
Peripheral nerve tumors
Intestinal desmoids
Inflammatory pseudo tumor
Inflammatory fibroid polyp

40. GIST

41. Peri-Rectal GIST

42. GIST

43. GIST

44. Peripheral Nerve Sheath Tumor

45. Peripheral Nerve Sheath Tumor

46. Peripheral Nerve Sheath Tumor

47. Solitary fibrous tumor

48. Immunostains for Spindle Cell Lesions
PKC theta
KIT
CD34
SMA
S-100
GIST
41/48 (85)
42/48 (88)
38/48 (79)
16/48 (33)
6/48 (13) LM
0/10 (0)
10/10 (100)
Sch
3/21 (14)
0/21 (0)
21/21 (100)
LMSrc
0/4 (0)
4/4 (100)
SFT
0/3 (0)
3/3 (100)
IFP
0/2 (0)
2/2 (100)
Motegi etal Pathol Int Mar;55(3):

49. Smooth Muscle Tumors

50. Leiomyosarcoma
DeMay

51. Diagnostic Algorithm Predominantly Small blue cells: Lymphoma
Small cell carcinoma
Metastasis from other known small blue cell neoplasm

52. Lymphoma

53. Lymphoma

54. Small Cell Carcinoma

55. Small Cell Carcinoma

56. Small Cell Carcinoma

57. Small Cell Carcinoma

58. Intra-abdominal Desmoplastic Small Round Cell Tumor
WT-1, Desmin, EMA, Vimentin, CK8, NSE
Granja N et al k - 11 Oct 2006

59. Reactive lymph nodule

60. http//:www.ipox.org (immunoquery)
Immunostains for Small Cell Tumors
Marker
CD68
CD45
CD20
Bcl2
Lymphoma - +
Granulocytic sarcoma
-/+
Neuroblastoma
SCLC (CK +)
http//: (immunoquery)

61. Immunostains for Small Cell Tumors
Marker
CD99
CD15
Syn
CD56
NB84
Des
Lymphoma + -
Granulocytic sarc
-/+
Neuroblastoma
SCLC (CK +)

62. Diagnostic Algorithm Mixed pattern: Endometriosis
Inflammatory pseudotumor
Diverticulosis

63. Endometriosis

64. Endometriosis

65. Inflammatory Myofibroblastic Tumor

66. Lamina propria

67. Peri-Rectal Teratoma

68. Tail Duct Cyst

69. Lipoma

70. Varices

71. Pneumatosis Coli

72. Lymphangioma

73. Ileal Conduit

74. Transitional Cell Carcinoma

75. EUS-FNA Diagnostic Performance for Gut lesions
Sensitivity %
Specificity %
Diagnostic Accuracy 89%

76. Staging

77. EUS-FNA Diagnostic Performance
In T-staging of esophageal or gastric cancers, the accuracy of EUS alone is 84% and 65%, respectively.

78. EUS-FNA Diagnostic Performance
The accuracy of EUS for N staging is 88% and 73%, respectively
When FNA is performed, the accuracy of N-staging reaches 95%

79. Pitfalls False negative: False positive: Lymphoma GIST
Sclerotic lesions specially signet cell carcinoma of the stomach
False positive:
Fragment of muscle misinterpreted as smooth muscle tumor and/or GIST.
Gut mucosal contaminant misinterpreted as cancer or metastasis in lymph nodes
Demay: The art and science of cytopathology