CIhtical Radiology(1992) 45, 185 186
Ultrasound-Guided Fine Needle Aspiration Cytology of Carcinoma Involving the Intra-Abdominal Oesophagus K. M. DAS, R. K O C H H A R * , N. M. G U P T A t , A. RAJWANSHI:~ and S_ S U R I
Departments of Radiodiagnosis, *Gastroenterology, ¢Surgery and ~Cytology, Post Graduate Institute of Medical Education and Research, Chandigarh, India Ultrasound-guided fine needle aspiration cytology (FNAC) of carcinoma of the intraabdominal oesophagus was attempted on 21 patients with a 21 G spinal needle using a percutaneous anterior epigastric approach. The results were compared with those of endoscopic biopsy and brush cytology. The ultrasound-guided FNAC had a positive yield in 20/21 (95.2%) compared with 18/21 (85.7%) for endoscopic biopsy and 18/21 (85.7%) for brush cytology (P>0.59). The combination of US-guided FNAC with endoscopic biopsy and the brush cytology achieved a positive yield in 21/21 (100%) whereas combining endoscopic biopsy and brush cytology produced a positive yield of 19/21 (90.5%). Two patients developed temporary epigastric pain. We recommend US-guided FNAC as a safe and effective technique that can be used alone or as an adjunct to endoscopic procedures for the diagnosis of carcinoma of the intraabdominal oesophagus. Das, K.M., Kochhar, R., Oupta, N.M., Rajwanshi, A. & Suri, S. (1992). Clinical Radiology 45, 185-186. Ultrasound-Guided Fine Needle Aspiration Cytology of Carcinoma Involving the Intra-Abdominal Oesophagus.
A definitive diagnosis of carcinoma of the oesophagus requires positive histology or cytology_ Endoscopic biopsy and brush cytology are two techniques commonly employed to achieve the diagnosis (Qizilbash et al., 1988). We describe the use of US-guided fine needle aspiration cytology (FNAC) in the diagnosis of carcinoma of the intra-abdominal oesophagus.
Liver~
Needle
~
tip
Oesophageal/~;._. ~
/~
_
P A T I E N T S AND M E T H O D S Twenty-one patients (12 males, 9 females, aged 32-65 years) with clinical and radiographic features suggesting malignancy of the intra-abdominal oesophagus were studied. All patients had a barium swallow examination followed by oesophagoscopy performed with an Olympus GIF-Q10 endoscope when the characteristics of the growth were noted and four to six biopsy pieces and brush cytology samples were taken. Patients were also examined by US using a 3.5 M H z or 5 M H z sector transducer (GE 3600) and US-guided F N A C of the tumour was performed. The technique used was as follows. After cleaning the skin and injecting local anaesthetic, a rigid 21 G, 0.6 m m (outer diameter) spinal needle was advanced through the left lobe of the liver into the tumour mass, under constant sonographic guidance using a free hand technique (Fig. 1). Using a 20 ml syringe mounted on a suction handle (Cameco, Sweden) two to three passes were made within the lesion. Suction was released and the handle removed. The aspirate was flushed on to clean glass slides, air dried and stained with May-Grunwald Giemsa stain. US-guided F N A C in all cases was performed within 48 h of the oesophagoscopy. For the evaluation of the diagnostic value of each procedure the )/2 test was applied. Correspondence to: K. M. Das, Department of Radio-Diagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh-160012, India.
(a)
(b) Fig. 1-Line-diagram (a) and the transverse sonographic image (b) of the abdominal oesophagusshowingthe hyperechoicneedle tip inside the tumour mass. RESULTS In all 21 patients the tumour involved the intraabdominal segment of the oesophagus and could be identified by sonography as a hypoechoic mass distorting the normal anatomical layers. Sonographically guided
I86
CLINICAL RADIOLOGY
Table 1 - Results of different diagnostic techniques in 21 patients
Type of tumour
No. of cases in which diagnosis confirmed by, Endoscopic biops)~
Polypoidal (n = 9) Ulcerative (n = 6) Infiltrative or stenotic (n - 6) Total (n=21)
Brush cytology
US-guided FNA C
9
8
9
5
6
5
4
4
6
18 (85.7%)
18 (85.7%)
20 (95.2%)
needle aspiration yielded adequate material in all the patients. The results o f the three diagnostic techniques are shown in Table l_ Of the 21 patients, 12 had squamous cell carcinomas and nine had adenocarcinomas. There was no disparity between the histological and the cytological diagnosis. C o m p a r i n g the results of the three techniques we found that in two patients with infiltrative t u m o u r both endoscopic biopsy and brush cytology were negative, whereas the US-guided F N A C was positive. Individually the endoscopic biopsy and brush cytology had a diagnostic yield o f 85.7% and the US-guided F N A C had a diagnostic yield of 95.2% (P > 0.59). Adding the results of F N A C with either biopsy or brush cytology achieved a diagnostic yield o f 100%. There was only one patient with a negative yield at US-guided F N A C and this patient had an ulcerative adenocarcinoma. The negative cytology was believed to result from a sampling error caused by extensive necrosis and ulceration o f the turnout. Two o f the 21 patients developed short-lived epigastric pain. There were no other complications.
logy. O u r results suggest that US-guided F N A C can be useful even in cases where endoscopic biopsy is negative. Percutaneous F N A C guided by imaging techniques has emerged as a safe and useful diagnostic modality for intra-abdominal lesions, with an accuracy of m o r e than 95% (Gazelle and Haaga, 1989). T u m o u r seeding in the aspiration tract is a rare complication, the incidence of which is approximately 0.006% (Smith, 1991). I n view of the natural history o f carcinoma o f the oesophagus, this risk is n o t considered significant_ D u r i n g s o n o g r a p h y and using a free h a n d technique, the needle tip can be monitored under constant real-time scanning, and injury to neighbouring structures such as the aorta can be avoided. It is for this reason that we prefer to use US guidance rather than p e r f o r m percutaneous F N A C as an adjunct to the barium swallow examination. M a n y patients with dysphagia are initially subjected to a barium swallow examination and if carcinoma o f the oesophagus is suspected an endoscopic study is performed and biopsies taken for histological diagnosis. W h e n carcin o m a o f the intra-abdominal oesophagus is suspected on a barium study, we can r e c o m m e n d US-guided F N A C as an alternative to endoscopy. This approach should be considered when endoscopy is not readily available, when the patient is unwilling to consent to endoscopy and when endoscopic biopsy has produced a negative result. We feel this technique can be reliably employed to obtain a pathological diagnosis of carcinoma o f the intra-abdominal oesophagus when this t u m o u r is suspected as a result o f a barium swallow examination.
Acknowledgements. The authors would like to thank Dr A. H, Chapman for his help and criticism.
REFERENCES
DISCUSSION Endoscopic brush cytology is sometimes used in addition to forceps biopsy to increase the diagnostic yield in patients suspected o f having carcinoma o f the oesophagus. There still remain a n u m b e r o f cases where a definitive diagnosis cannot be made. The percentage o f false negative results is m u c h higher in malignancies with a necrotic surface, stenosing lesions in and around the gastro-oesophageal junction, infiltrative tumours and submucosal masses (Witzel et al., 1976; Tabibian et al., 1986; Qizilbash et al., 1988). Endoscopic F N A C has been shown to increase the diagnostic yield in such cases ( K o c h h a r et al., 1988). The present report describes the application o f the US-guided F N A C to tumours involving the abdominal portion of the oesophagus. Earlier workers have described the use of US in the demonstration o f tumours of the stomach and cardia (Derchi et al., 1983) and recently, in a preliminary report, Green et al. (1988) have shown the usefulness of the US-guided F N A C in three patients with carcinoma of the stomach who had negative endoscopic biopsies and brush cyto-
Derchi, LE, Biggi, E, Neumaier, CE & Cicico, GR (1983). Ultrasonographic appearances of gastric cancer. British Journal of Radiology, 56, 365 370. Gazelle, GS & Haaga, JR (1989). Guided percutaneous biopsy of intraabdominal lesions. American Journal of Roentgenology, 153, 929-935. Green, J, Katz, S, Phillips, G, Bank, S, Ilardi, C, Hadju, E et al. (1988). Percutaneous sonographic needle aspiration biopsy of endoscopitally negative gastric carcinoma. American Journal of Gastroenterology, 83, 1150-1154. Kochhar, R, Rajwanshi, A, Malik, AK, Gupta, SK & Mehta, SK (1988). Endoscopic fine needle aspiration biopsy of gastroesophageal lesions. Gastrointestinal Endoscopy, 34, 321 323. Qizilbash, AH, Castelli, M, Kowalski, MA & Churley, A (1988). Endoscopic brush cytology and biopsy in the diagnosis of cancer of upper gastrointestinal tract. Acta Cytologica, 24, 313-318. Smith, EH (1991). Complication of percutaneous abdominal fine needle biopsy. Radiology, 178, 253-258. Tabibian, N, Smith, JL, Schwartz, JT, McHenry, MM & Graham, DY (1986). Endoscopic needle biopsy of gastrointestinal lesions (abstract). Gastrointestinal Endoscopy, 32, 175. Witzel, L, Halter, F, Gretillat, PA, Scheurer, W & Keller, M (1976). Evaluation of specific value of endoscopic biopsies and brush cytology for malignancy of the esophagus and stomach. Gut, 17, 375-377.
Ultrasound-Guided Fine Needle Aspiration Cytology of Carcinoma Involving the Intra-Abdominal Oesophagus K. M. DAS, R. K O C H H A R * , N. M. G U P T A t , A. RAJWANSHI:~ and S_ S U R I
Departments of Radiodiagnosis, *Gastroenterology, ¢Surgery and ~Cytology, Post Graduate Institute of Medical Education and Research, Chandigarh, India Ultrasound-guided fine needle aspiration cytology (FNAC) of carcinoma of the intraabdominal oesophagus was attempted on 21 patients with a 21 G spinal needle using a percutaneous anterior epigastric approach. The results were compared with those of endoscopic biopsy and brush cytology. The ultrasound-guided FNAC had a positive yield in 20/21 (95.2%) compared with 18/21 (85.7%) for endoscopic biopsy and 18/21 (85.7%) for brush cytology (P>0.59). The combination of US-guided FNAC with endoscopic biopsy and the brush cytology achieved a positive yield in 21/21 (100%) whereas combining endoscopic biopsy and brush cytology produced a positive yield of 19/21 (90.5%). Two patients developed temporary epigastric pain. We recommend US-guided FNAC as a safe and effective technique that can be used alone or as an adjunct to endoscopic procedures for the diagnosis of carcinoma of the intraabdominal oesophagus. Das, K.M., Kochhar, R., Oupta, N.M., Rajwanshi, A. & Suri, S. (1992). Clinical Radiology 45, 185-186. Ultrasound-Guided Fine Needle Aspiration Cytology of Carcinoma Involving the Intra-Abdominal Oesophagus.
A definitive diagnosis of carcinoma of the oesophagus requires positive histology or cytology_ Endoscopic biopsy and brush cytology are two techniques commonly employed to achieve the diagnosis (Qizilbash et al., 1988). We describe the use of US-guided fine needle aspiration cytology (FNAC) in the diagnosis of carcinoma of the intra-abdominal oesophagus.
Liver~
Needle
~
tip
Oesophageal/~;._. ~
/~
_
P A T I E N T S AND M E T H O D S Twenty-one patients (12 males, 9 females, aged 32-65 years) with clinical and radiographic features suggesting malignancy of the intra-abdominal oesophagus were studied. All patients had a barium swallow examination followed by oesophagoscopy performed with an Olympus GIF-Q10 endoscope when the characteristics of the growth were noted and four to six biopsy pieces and brush cytology samples were taken. Patients were also examined by US using a 3.5 M H z or 5 M H z sector transducer (GE 3600) and US-guided F N A C of the tumour was performed. The technique used was as follows. After cleaning the skin and injecting local anaesthetic, a rigid 21 G, 0.6 m m (outer diameter) spinal needle was advanced through the left lobe of the liver into the tumour mass, under constant sonographic guidance using a free hand technique (Fig. 1). Using a 20 ml syringe mounted on a suction handle (Cameco, Sweden) two to three passes were made within the lesion. Suction was released and the handle removed. The aspirate was flushed on to clean glass slides, air dried and stained with May-Grunwald Giemsa stain. US-guided F N A C in all cases was performed within 48 h of the oesophagoscopy. For the evaluation of the diagnostic value of each procedure the )/2 test was applied. Correspondence to: K. M. Das, Department of Radio-Diagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh-160012, India.
(a)
(b) Fig. 1-Line-diagram (a) and the transverse sonographic image (b) of the abdominal oesophagusshowingthe hyperechoicneedle tip inside the tumour mass. RESULTS In all 21 patients the tumour involved the intraabdominal segment of the oesophagus and could be identified by sonography as a hypoechoic mass distorting the normal anatomical layers. Sonographically guided
I86
CLINICAL RADIOLOGY
Table 1 - Results of different diagnostic techniques in 21 patients
Type of tumour
No. of cases in which diagnosis confirmed by, Endoscopic biops)~
Polypoidal (n = 9) Ulcerative (n = 6) Infiltrative or stenotic (n - 6) Total (n=21)
Brush cytology
US-guided FNA C
9
8
9
5
6
5
4
4
6
18 (85.7%)
18 (85.7%)
20 (95.2%)
needle aspiration yielded adequate material in all the patients. The results o f the three diagnostic techniques are shown in Table l_ Of the 21 patients, 12 had squamous cell carcinomas and nine had adenocarcinomas. There was no disparity between the histological and the cytological diagnosis. C o m p a r i n g the results of the three techniques we found that in two patients with infiltrative t u m o u r both endoscopic biopsy and brush cytology were negative, whereas the US-guided F N A C was positive. Individually the endoscopic biopsy and brush cytology had a diagnostic yield o f 85.7% and the US-guided F N A C had a diagnostic yield of 95.2% (P > 0.59). Adding the results of F N A C with either biopsy or brush cytology achieved a diagnostic yield o f 100%. There was only one patient with a negative yield at US-guided F N A C and this patient had an ulcerative adenocarcinoma. The negative cytology was believed to result from a sampling error caused by extensive necrosis and ulceration o f the turnout. Two o f the 21 patients developed short-lived epigastric pain. There were no other complications.
logy. O u r results suggest that US-guided F N A C can be useful even in cases where endoscopic biopsy is negative. Percutaneous F N A C guided by imaging techniques has emerged as a safe and useful diagnostic modality for intra-abdominal lesions, with an accuracy of m o r e than 95% (Gazelle and Haaga, 1989). T u m o u r seeding in the aspiration tract is a rare complication, the incidence of which is approximately 0.006% (Smith, 1991). I n view of the natural history o f carcinoma o f the oesophagus, this risk is n o t considered significant_ D u r i n g s o n o g r a p h y and using a free h a n d technique, the needle tip can be monitored under constant real-time scanning, and injury to neighbouring structures such as the aorta can be avoided. It is for this reason that we prefer to use US guidance rather than p e r f o r m percutaneous F N A C as an adjunct to the barium swallow examination. M a n y patients with dysphagia are initially subjected to a barium swallow examination and if carcinoma o f the oesophagus is suspected an endoscopic study is performed and biopsies taken for histological diagnosis. W h e n carcin o m a o f the intra-abdominal oesophagus is suspected on a barium study, we can r e c o m m e n d US-guided F N A C as an alternative to endoscopy. This approach should be considered when endoscopy is not readily available, when the patient is unwilling to consent to endoscopy and when endoscopic biopsy has produced a negative result. We feel this technique can be reliably employed to obtain a pathological diagnosis of carcinoma o f the intra-abdominal oesophagus when this t u m o u r is suspected as a result o f a barium swallow examination.
Acknowledgements. The authors would like to thank Dr A. H, Chapman for his help and criticism.
REFERENCES
DISCUSSION Endoscopic brush cytology is sometimes used in addition to forceps biopsy to increase the diagnostic yield in patients suspected o f having carcinoma o f the oesophagus. There still remain a n u m b e r o f cases where a definitive diagnosis cannot be made. The percentage o f false negative results is m u c h higher in malignancies with a necrotic surface, stenosing lesions in and around the gastro-oesophageal junction, infiltrative tumours and submucosal masses (Witzel et al., 1976; Tabibian et al., 1986; Qizilbash et al., 1988). Endoscopic F N A C has been shown to increase the diagnostic yield in such cases ( K o c h h a r et al., 1988). The present report describes the application o f the US-guided F N A C to tumours involving the abdominal portion of the oesophagus. Earlier workers have described the use of US in the demonstration o f tumours of the stomach and cardia (Derchi et al., 1983) and recently, in a preliminary report, Green et al. (1988) have shown the usefulness of the US-guided F N A C in three patients with carcinoma of the stomach who had negative endoscopic biopsies and brush cyto-
Derchi, LE, Biggi, E, Neumaier, CE & Cicico, GR (1983). Ultrasonographic appearances of gastric cancer. British Journal of Radiology, 56, 365 370. Gazelle, GS & Haaga, JR (1989). Guided percutaneous biopsy of intraabdominal lesions. American Journal of Roentgenology, 153, 929-935. Green, J, Katz, S, Phillips, G, Bank, S, Ilardi, C, Hadju, E et al. (1988). Percutaneous sonographic needle aspiration biopsy of endoscopitally negative gastric carcinoma. American Journal of Gastroenterology, 83, 1150-1154. Kochhar, R, Rajwanshi, A, Malik, AK, Gupta, SK & Mehta, SK (1988). Endoscopic fine needle aspiration biopsy of gastroesophageal lesions. Gastrointestinal Endoscopy, 34, 321 323. Qizilbash, AH, Castelli, M, Kowalski, MA & Churley, A (1988). Endoscopic brush cytology and biopsy in the diagnosis of cancer of upper gastrointestinal tract. Acta Cytologica, 24, 313-318. Smith, EH (1991). Complication of percutaneous abdominal fine needle biopsy. Radiology, 178, 253-258. Tabibian, N, Smith, JL, Schwartz, JT, McHenry, MM & Graham, DY (1986). Endoscopic needle biopsy of gastrointestinal lesions (abstract). Gastrointestinal Endoscopy, 32, 175. Witzel, L, Halter, F, Gretillat, PA, Scheurer, W & Keller, M (1976). Evaluation of specific value of endoscopic biopsies and brush cytology for malignancy of the esophagus and stomach. Gut, 17, 375-377.
