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Diagnosis of metastatic disease is important in patients with cirrhosis and hepatocellular carcinoma (HCC) to prevent futile liver transplantation. Some of these patients have metastatic lymphadenopathy; however, it is difficult to perform percutaneous fine-needle aspiration due to presence of collateral and anatomic location. Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) of lymph nodes offers several advantages like real-time vision, proximity to target, and avoidance of collaterals. The aim of this study was to look for metastatic lymphadenopathy by EUS-guided FNA (EUS-FNA) in prospective liver transplant recipients with HCC. A prospective study was conducted from January 2013 to January 2016 at a tertiary care center. All prospective liver transplant recipients with HCC had PET-CT and bone scan to look for metastatic disease. EUS-FNA was done in patients with abdominal or mediastinal lymphadenopathy and no evidence of extrahepatic disease. Data is shown as median (25–75 interquartile range). EUS-guided FNA was done for 50 patients (42 abdominal and 8 mediastinal lymph nodes), age 57 (53–62) years, Child-Turcotte-Pugh 7 (6–9), and model for end-stage liver disease 10 (7–16). FNA material was adequate in 92% patients, metastasis in 15 (30%), granulomatous lymphadenopathy in 4 (8%), and reactive change in 27 patients (54%). The material was inadequate for diagnosis in 4 (8%) patients. Thus, EUS-guided FNA precluded transplantation in 30% of patients with lymphadenopathy, and 4 (8%) patients received anti-tubercular therapy before liver transplantation. In patients with HCC and lymphadenopathy, EUS-guided FNA detected metastatic disease and precluded liver transplantation in approximately one third of patients.

Tuberculosis is a common disease in India with significant morbidity and mortality. Limited data is available on the description of tubercular lymphadenopathy on endoscopic ultrasound. Retrospective data of 116 lymph nodes in 113 patients was evaluated at a tertiary care center. Lymphadenopathy in the mediastinum and abdomen were included. The study was aimed at identifying the endoscopic ultrasound (EUS) features of tubercular lymphadenopathy and comparing them with reactive lymphadenopathy in patients with pyrexia of unknown origin. The following features were suggestive of tubercular lymphadenopathy (n = 55) as compared to reactive lymphadenopathy (n = 61): hypoechoic echotexture (94.5 % vs. 75.4 %, p 0.004), patchy anechoic/hypoechoic areas (30.2 % vs. 0 %, p = 0.000), calcification (24.5 % vs. 0 %, p = 0.000), sharply demarcated borders (34.5 % vs. 9.8 %, p = 0.001), pus like material on aspirate (18.2 % vs. 0 %, p 0.000), and conglomeration of lymph nodes (10.9 % vs. 0 %, p = 0.009). The tubercular lymph nodes were significantly larger than reactive nodes at long axis and short axis diameter (2.4 ± 1.1 vs. 1.6 ± 0.6 cm, p

A plasmacytoma is a discrete, solitary mass of neoplastic monoclonal plasma cells found in either bone marrow or a soft tissue site. It can occur as a solitary lesion or could be an extramedullary presentation of multiple myeloma. A diagnosis of plasmacytoma should prompt further clinical, biochemical and radiologic investigations to determine whether the lesion is truly solitary or in fact a localized presentation of multiple myeloma [1].

Objective Histoplasmosis is an infectious disease caused by the dimorphic fungus Histoplasma capsulatum, endemic in central and eastern states of United States, South America and Africa. India is considered to be non-endemic area for histoplasmosis. Disseminated histoplasmosis may affect almost all systems. Disseminated histoplasmosis with asymptomatic adrenal involvement has been described in immunocompromised patients; whereas isolated adrenal involvement with adrenal insufficiency as the presenting manifestation of the disease is rare. Material and method Twelve patients from a non-endemic area with adrenal histoplasmosis, who were immunocompetent and diagnosed as adrenal histoplasmosis by cytology/histopathology between January 2012 to December 2014 were studied. 18F-FDG PET/CT (fluorodeoxyglucose positron emission tomography/computed tomography) was used to assess the extent of involvement. Results There were a total of 12 immunocompetent males (mean age: 56.9 years). Ten patients had bilateral adrenal involvement and two had a unilateral left adrenal mass. All the patients had histopathologically/cytologically proven adrenal histoplasmosis. Two patients had simultaneous histoplasmosis of other sites, one in the epiglottis and the other in the alveolus. 18F-FDG PET/CT was performed in 10 patients showing high FDG uptake in the adrenals. All these patients received Amphotericin B and/or Itraconazole treatment that led to symptomatic improvement. Conclusion A diagnosis of invasive fungal infection requires a high index of suspicion, especially in immunocompetent patients who present with nonspecific symptoms, clinical signs, laboratory and radiological features that can resemble adrenal neoplasms. Clinical specimens must be sent for cytopathology/histopathology together with fungal culture for a definite diagnosis and appropriate management.

BACKGROUND/AIMS Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) cytology of adrenal masses helps in etiological diagnosis. The aim of this study was to evaluate the diagnostic yield of EUS-FNA of adrenal masses in cases where other imaging methods failed and/or were not feasible. METHODS Twenty-one consecutive patients with adrenal masses, in whom adrenal FNA was performed because conventional imaging modalities failed and/or were not feasible, were prospectively evaluated over a period of 3 years. RESULTS Of the 21 patients (mean age, 56±12.2 years; male:female ratio, 2:1), 12 had pyrexia of unknown origin and the other nine underwent evaluation for metastasis. The median lesion size was 2.4×1.6 cm. Ten patients were diagnosed with tuberculosis (shown by the presence of caseating granulomas [n=10] and acid-fast bacilli [n=4]). Two patients had EUS-FNA results suggestive of histoplasmosis. The other patients had metastatic lung carcinoma (n=6), hepatocellular carcinoma (n=1), and adrenal lipoma (n=1) and adrenal myelolipoma (n=1). EUS results were not suggestive of any particular etiology. No procedure-related adverse events occurred. CONCLUSIONS EUS-FNA is a safe and effective method for evaluating adrenal masses, and it yields diagnosis in cases where tissue diagnosis is impossible or has failed using conventional imaging modalities.

Malignant Mesothelioma of Pleura is a rare tumor, which presents with chest pain & pleural effusion. It needs to be distinguished from pulmonary adenocarcinoma, which may be very difficult or even impossible task at the routine cytology & H&E level. Therefore a panel of immunohistochemical markers is required to reach the correct diagnosis.

stinal lymphadenopathy diagnosed by endoscopic ultrasound-guided fine-needle aspiration A 41-year-old man from Afghanistan presented with pyrexia of unknown origin and weight loss for 2 months. His work-up revealed anemia (hemoglobin 7.7g/dL) and leukopenia (2990 cells/μL), and he was positive for human immunodeficiency virus type 1 (HIV 1). A contrast-enhanced computed tomography of the chest and abdomen was performed, and showed small mediastinal lymph nodes with normal abdominal imaging. Endoscopic ultrasound (EUS) of the mediastinal nodes showed a few small nodes at the subcarinal window, the largest of whichmeasured 1.2×0.6cm. These lymph nodes had defined borders, were triangular in shape, and some had a hyperechoic center suggestive of reactive change (●" Fig.1). Fine-needle aspiration (FNA) of a larger lymph node (●" Fig.2) was performed because the patient did not want to undergo bone marrow examination. One needle pass with suction was made using an EchoTip 22-gauge needle (Wilson-cook Medical, Winston-Salem, North Carolina, United States). Cytopathology of the lymph node revealed numerous Leishmania donovani bodies inside and outside histiocytes (●" Fig.3). The patient was offered amphotericin B treatment, but preferred to receive treatment in his home country due to financial difficulties. This case illustrates the safety of performing EUS-FNA of small lymph nodes in the mediastinum where numerous vascular structures are located, and the importance of obtaining a tissue diagnosis even from small lymph nodes if it is indicated (the present case had pyrexia of unknown origin and immunocompromised status). Autopsy studies of the mediastinum have shown that lymph nodes that are up to 1cm in the short axis are reactive in nature [1,2]. The present case also demonstrates the limitation of morphological EUS criteria for differentiating between reactive and pathological lymph nodes. The Leishmania parasite can be isolated from bone marrow, spleen, liver, and lymph nodes. Leishmaniasis in HIV-positive patients may present atypically, as in the present case in which no organomegaly was seen [3]. Leishmaniasis presenting as isolated lymphadenitis is rare and should be included in the differential diagnosis in immunocompromised patients [3,4]. Fig.3 Cytopathology image showing numerous Leishmania donovani bodies inside and outside histiocytes (Giemsa stain,×100). Fig.1 Endoscopic ultrasound image showing two small lymph nodes at the subcarinal window (labeled as 1 and 2). LA, left atrium; PA, pulmonary artery.

Background: Plasmablastic lymphoma (PL) is a relatively new category of lymphoma, which has been considered to be found predominantly in the oral cavity and has a strong association with HIV. Case: We report a case of extraoral/mesenteric PL detected using cytological examination of ascitic fluid assisted by flow cytometric (FC) analysis. The cells were positive for CD38, CD138, CD10, CD45 and CD56 and negative for CD3, CD19, CD20 and CD79a, with cytoplasmic lambda light-chain restriction. We also reviewed 67 cases of extraoral PL from the available literature and found them to be less often associated with HIV (than oral PL), occurring mostly in males aged 30-60 years, with the most common extraoral site being the anorectal region. Conclusion: A high index of suspicion at the level of the cytopathologist is imperative for identifying lymphoma cells in a body fluid. A rare entity like PL can also be diagnosed on cytology assisted by ancillary techniques (like FC), without the need for a biopsy. We also suggest that the minimum panel to diagnose PLs should include CD138, MUM-1, Ki-67, ALK-1, CD3, immunoglobulin light-chains, CD20 and PAX5.

Background and study aim Different types of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) techniques are used in clinical practice; the best method in terms of outcome has not been determined. The aim of the study was to compare the diagnostic adequacy of aspirated material, and the cytopathological and EUS morphological features between capillary action, suction, and no-suction FNA methods. Patients and methods This was a prospective, single-blinded, randomized study conducted at a tertiary care hospital. Patients were randomized to the three groups: capillary action, suction, and no suction. A total of 300 patients were included, with 100 patients in each arm. Results A total of 300 patients (195 males) underwent EUS-FNA of 235 lymph nodes and 65 pancreatic masses (distribution not statistically different between the groups). The mean age was 52 ± 14 years. A 22 gauge needle was used in the majority (93 %) of procedures. There was no statistical difference between the three groups regarding lymph node size at the largest axis and ratio, type of needle, echo features, echogenicity, calcification, necrosis, shape, borders (lymph nodes), number of passes, and cellularity. Diagnostic adequacy of the specimen was 91 %, 91 %, and 94 % in the capillary, suction, and no suction groups, respectively (P = 0.67). Significantly more slides and blood clots were generated by the suction method compared with the other methods. Conclusion The capillary action, suction, and no suction methods of EUS-FNA are similar in terms of diagnostic adequacy of the specimen. The suction method has the disadvantages of causing more bleeding and generating more slides.

ALVEOLAR soft-part sarcoma (ASPS) is a rare, aggressive malignancy of uncertain histologic origin seen in young adults. It comprises 0.5-1 % of all soft tissue sarcomas. Usual age of presentation is 15-35 years and site is lower extremities in adults and head and neck in infants and children. It is a slowly growing tumor, however vascular emboli are common and metastasis to the lung or brain may be the first manifestation of the disease. Characteristic cytological features corelate well with histology.