Tuberculosis is still the most Common Cause of Mediastinal and Intra-abdominal Lymphadenopathy by EUS-FNA in India

Background Lymph nodal tuberculosis is reported to occur in 4% to 7% of all tuberculosis, and mediastinal lymphadenopathy accounts for 10% of lymph nodal tuberculosis but the diagnosis still remains a challenge due to inaccessibility to these sites. There is a scarcity of recent data from India about the etiology of intra-abdominal and mediastinal lymphadenopathy despite being frequently detected in cross-sectional imaging. Methods A retrospective study was conducted after reviewing hospital records over a period of 3 years from December 2017 to December 2020 who underwent endoscopic ultrasonography (EUS). A total of 126 patients with mediastinal and/or intra-abdominal lymphadenopathy detected by cross-sectional imaging were examined for clinical features, EUS, and histopathology records. Results The mean age of patients was 53.12 ± 14.15 years. Seventy-one patients (56%) had intra-abdominal lymph nodes and 55 (44%) had mediastinal lymph nodes. The average number of needle passes was 2.35 ± 0.58 (range: 2–4). The majority of patients had tubercular etiology (53.2%) followed by metastatic (26.2%). Other etiologies were reactive (4.8%), lymphoma (4.8%), sarcoidosis (3.2%), and GIST (1.6%). No diagnosis could be ascertained in 6.3% of patients. The EUS features that favored tubercular etiology over metastatic were heterogeneous echotexture (72% vs. 30%), irregular shape (78% vs. 12%), indistinct borders (81% vs. 30%) and calcification (43% vs. 15%). Partial anechoic area and hyperechoic area were seen in 21% and 64% of tubercular patients, respectively. EUS only had sensitivity and specificity of 63% and 84%, respectively, and EUS FNA had a very high sensitivity and specificity of 93% and 100%, respectively. Conclusion Tuberculosis is still the most common cause of lymph nodes. EUS FNA had a very high sensitivity and specificity of 93% and 100%, respectively, for the diagnosis of mediastinal and intra-abdominal lymphadenopathy.

Diagnostic Performance of EUS-Guided Sampling in Indeterminate Radiological Diagnosis of Pancreatic Disease and Intra-Abdominal Lymphadenopathy

Background: Endoscopic ultrasound (EUS)-guided sampling has been widely used for pathologic diagnosis of pancreatic lesions and intra-abdominal lymphadenopathy. However, its effectiveness for diagnostic decision making in indeterminate radiological diagnosis has not been well determined. Materials and Methods: From March 2012 to October 2015, 98 consecutive patients who underwent EUS-guided FNA for solid intra-abdominal lesions were retrospectively analyzed (100 procedures). The purpose of EUS-guided sampling was classified as (1) confirmation of a high-confidence radiological diagnosis (High-confidence group) or (2) decision making in the differential diagnostic dilemma for indeterminate radiological diagnosis (Indeterminate group). The accuracies of EUS-guided sampling according to the purpose were analyzed and then compared. Results: Of the 100 procedures, 22 procedures (22%) came under the Indeterminate group, whereas 78 came under the High-confidence group. The accuracies did not differ between the Indeterminate and the High-confidence groups (86.4% vs. 88.5%, p = 1.000). Clinical conditions that required EUS-guided sampling for indeterminate radiological diagnosis were (1) pancreatic cancer vs. benign disease (n = 8; e.g., pancreatic cancer vs. mass-forming pancreatitis), (2) recurrence of previous/pre-existing cancer vs. benign disease (n = 5; e.g., recurrent gastric cancer vs. reactive lymph node), (3) pathologic differentiation of presumed malignancy (n = 6; e.g., lymphadenopathies in the previous history of esophageal cancer and colon cancer), or (4) miscellaneous (n = 3; e.g., tuberculous lymphadenopathy vs. other condition). Conclusions: EUS-guided sampling demonstrated an accuracy of 86.4% in the clinical setting of indeterminate radiological diagnosis, which was not different from that of the confirmation of high-confidence diagnosis.

Secondary Metastatic Gastric Melanoma

Gastrointestinal melanomas are commonly metastatic from a cutaneous origin. They cause significant cancer related mortality. A 47- year - old male patient presented with severe pallor and prostration due to profuse upper GI bleeding. He was urgently managed with fluid and blood transfusion. Endoscopy revealed gastric mass and CT showed gastric neoplasm with abdominal lymphadenopathy but endoscopic biopsy revealed inflammatory lesion. He had history of malignant melanoma of right third toe three years back which was managed with surgery and chemotherapy. Exploratory laparotomy was done and biopsy was taken from gastric lesion as well as enlarged lymph nodes. Histopathology revealed melanoma from both specimens. Prognosis is bad. Counseling and collaboration with different relevant disciplines are essential. Management is directed to symptom relieve as well as lengthening survival. J Bangladesh Coll Phys Surg 2021; 39(1): 68-75

Systemic mastocytosis with chronic myelomonocytic leukemia followed by transformation into acute myeloid leukemia

IntroductionSystemic mastocytosis (SM) with an associated hematological neoplasm (SM-AHN) constitutes about 40% of all patients with SM. AHN commonly includes myeloid neoplasms and chronic myelomonocytic leukemia (CMML) is seen in about 30% of these patients.Case reportA 67-year-old male presented to hematologist with fatigue and significant weight loss. Abdominal ultrasound and computed tomography (CT) detected hepatosplenomegaly, abdominal lymphadenopathy, and ascites. He was anemic with leukocytosis and eosinophilia. Trephine biopsy showed > 30% of spindle-shaped mast cells. The KITD816V mutation was present. Serum tryptase level was elevated to 62 ng/mL. The patient was diagnosed with aggressive SM and received six cycles of cladribine with partial response. Three years later, he developed severe anemia. Eosinophilia and monocytosis (5.6 × 109/L) were demonstrated in blood film. Hepatosplenomegaly and abdominal lymphadenopathy were also present. Trephine biopsy did not demonstrate the presence of spindle-shaped mast cells, but dysplasia in erythroid and myeloid lineages was evident. The histological result of lymph node biopsy as well as blood and bone marrow findings were in line with CMML. He received hydroxyurea, but he transformed soon into fatal acute monocytic leukemia.ConclusionsThe prognosis of SM-AHN depends on AHN component. Leukemic transformation of AHN component may occur in a proportion of patients.