P1727 - Spindle Cell Neoplasms of the Upper Gastrointestinal Tract, Adequate Tissue Acquisition and Histomorphologic Analysis by Using EUS-Guided Low Cost Multilayer Coil Sheathed Nitinol-Based FNA Needle: Review of Five Cases

Monday, October 25, 2021

10:30 AM – 4:15 PM PT

Location: Shoreline Exhibit Hall

Has Audio

Presenting Author(s)

Hemanta Kumar Nayak, DM

All India Institute of Medical Sciences
Bhubaneswar, Orissa, India

Hemanta Kumar Nayak, DM, Chandan Kumar, MD, Mohd Imran Chouhan, MD, Bramhadatta Pattnaik, , Chinmyee Panigrahi, , Susama Patra, , Abhijeet Rai, , Manas Kumar Panigrahi, DM, Subash Chandra Samal, DM
All India Institute of Medical Sciences, Bhubaneswar, Orissa, India

Introduction: Acquisition of cells or tissue using endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has been used for decades. More recently various specially designed FNB(Fine needle biopsy) needle is available for better tissue acquisition and histomorphological analysis. However to improve tissue acquisition, newly available EZ Shot 3 Plus (Olympus, Tokyo, Japan)FNA needle was changed from conventional stainless steel to Nitinol, and the covering material was changed from plastic to a multicoiling sheath. These changes have increased the tissue acquisition even from a difficult locations and can be used for taking biopsy. In addition, due to relatively lower price, it can be used in resource limited settings as well.

Case Description/Methods: This was a retrospective analysis of 5 patients of suspected upper gastrointestinal suspected neoplasm of which 3 patients having exophytic lesion arising from stomach and 2 patients having lesion at paraduodenal location (Table 1). After initial evaluation by CT scan and oesophagogastroduodenoscopy, all patient underwent EUS evaluation and underwent FNB by using the nitinol based FNA needle EZ Shot 3 Plus (Olympus, Tokyo, Japan). Tissue acquisition was adequate for histomorphology and immunohistochemistry analysis. Definite diagnosis of GIST was established in 2 patient, malignant GIST in one, benign spindle cell neoplasm in one and paraganglioma in one (Table 1). Malignant GIST and another patient of GIST received multikinase inhibitors to reduce the size and all other patients planned for surgical resection.

Discussion: EUS guided adequate tissue acquisition is challenging. Various technical and anatomical factors such as exact identification of lesion and its location, appropriate penetration technique,angulation, and availability of onsite pathologist are all critical to achieve good quality and quantity of tissue.In this new FNA needle, modification such as conventional stainless steel to Nitinol, and multicoiling sheath increases the tissue acquisition rate even from the most difficult location.

Keywords:

EUS FNA needle, Spindle cell neoplasm

Figure: Figure 1,Panel A:Asymmetrical wall thickening at fundus with exophytic mass of size 15x15cm with predominant cystic component extending upto pancreatic tail and splenic hilum
Figure 1,Panel B:EUS showed a well defined lesion (size=10x10cm),mixed echogenicity, predominately solid component with cystic cavity,
arising from 4th layer of stomach extending upto splenic hilum and pancreatic tail.
Figure 1,Panel C:EUS showed a well defined large hypoechoic lesion (size=10x10 cm) arising from 4th layer of gastric wall.
Figure 1, Panel D:EUS showed a well-defined heteroechoic lesion (size 5x5cm) seen in paraduodenal space with a central cystic space.
Upper part of mass extending upto lower pole of right kidney.
Figure 1, Panel E: EUS guided biopsy showed solid-cystic spindle cell tumor with predominant area of haemorrhage. Cells are arranged in long and short fascicles. They are mildly pleomorphic with elongated hyperchromatic inconcipious nuclei and cytoplasmic vacuolation. No evidence of necrosis or nuclear atypia is seen. Mitotic figure is not seen.
Figure 1, Panel F:Tumor cells are strongly and diffusely immunopositive for CD117, suggestive of GIST.

Parameters/ Investigation	CASE 1	CASE 2	CASE 3	CASE 4	CASE 5
Symptoms Duration	Epigastric pain, Abdominal distension -Intermittent melena 2 month	Left upper abdominal pain Early satiety, Anorexia Weight loss 2 month	-Intermittent epigastric pain without vomiting -Early satiety -Weight loss 3 month	-Intermittent hematemesis,Melena 2 month	-Abdominal pain 2 month
CECT abdomen	-Moderate ascites, dilated portal vein -Large hypodense exophytic growth arising from gastric body extending to left lobe of liver.	Asymmetrical wall thickening at fundus with exophytic mass of size 15x15cm with predominant cystic component extending upto pancreatic tail and splenic hilum	Hetrogenously enhancing isolated mass lesion (size=5.5x5.1x5.7cm) with central necrosis arising from junction of 2^nd and 3^rd part of duodenum	Exophytic growth of approximate size 4x4 cm probably arising from gastric fundus and proximal gastric body	Right paracaval (size=5x5cm ) attaching to lower pole of right kidney and 2^nd and 3^rd part of duodenum
EUS (Linear)	At gastric station: Well defined large hypoechoic lesion (size=10x10 cm) arising from 4^th layer of gastric wall.	At gastric station: Well defined lesion (size=10x10cm),mixed echogenicity, predominately solid component with cystic cavity, -No increased vascularity. - Arising from 4^th layer of stomach extending upto splenic hilum and pancreatic tail.	At D2 station: Well-defined hypoechoic mass (size= 4x4cm) seen at paraduodenal location extending upto upper pole of right kidney.	At gastric station: Well defined hypoechoic lesion (size= 5x5cm) arising from 4^th layer of stomach. Mass is not encasing the spleen or body and tail of pancreas	Well-defined heteroechoic lesion (size 5x5cm) seen in paraduodenal space with a central cystic space. Upper part of mass extending upto lower pole of right kidney.
Histopathology	Elongated stellate shaped cell with round to oval hyperchromatic nuclei. Loose intervening stroma with many vascular channels. Occasional mitotic figures seen. Tumour cells focal positive for C-KIT, diffusely positive for SMA, muscle specific actin with proliferative index of 20% (MIBI is 20%)	Solid-cystic spindle cell tumor with predominant area of haemorrhage. Cells are arranged in long and short fascicles. They are mildly pleomorphic with elongated hyperchromatic inconcipious nuclei and cytoplasmic vacuolation. No evidence of necrosis or nuclear atypia is seen. Mitotic figure is not seen. Tumor cells are strongly and diffusely immunopositive for CKIT (membranocytoplasmic) and negative for SMA.	Short fascicles and bundles of spindle cells with elongated and pleomorphic nuclei. Necrosis present. No mitosis. Tumor cells diffusely positive for SMA while negative for cKIT and S100.	Spindle cells arranged in cohesive cluster with elongated and hyperchromatic nuclei. No mitosis, pleomorphism and necrosis. Tumor cells diffusely positive for cKIT.	Clusters of polygonal cells with abundant pale, granular, basophilic cytoplasm. -Nuclei are round to oval hyperchromatic and mildly pleomorphic. -Tumor cells diffusely positive for S-100 and negative for CD117
Pathological impression	Suggestive of Malignant GIST.	Suggestive of GIST.	Suggestive of benign spindle cell tumours.	Suggestive of GIST.	Suggestive of paraganglioma

Table: Table 1: Summary of case details

Disclosures:

Hemanta Kumar Nayak indicated no relevant financial relationships.

Chandan Kumar indicated no relevant financial relationships.

Mohd Imran Chouhan indicated no relevant financial relationships.

Bramhadatta Pattnaik indicated no relevant financial relationships.

Chinmyee Panigrahi indicated no relevant financial relationships.

Susama Patra indicated no relevant financial relationships.

Abhijeet Rai indicated no relevant financial relationships.

Manas Kumar Panigrahi indicated no relevant financial relationships.

Subash Chandra Samal indicated no relevant financial relationships.

Hemanta Kumar Nayak, DM, Chandan Kumar, MD, Mohd Imran Chouhan, MD, Bramhadatta Pattnaik, , Chinmyee Panigrahi, , Susama Patra, , Abhijeet Rai, , Manas Kumar Panigrahi, DM, Subash Chandra Samal, DM. P1727 - Spindle Cell Neoplasms of the Upper Gastrointestinal Tract, Adequate Tissue Acquisition and Histomorphologic Analysis by Using EUS-Guided Low Cost Multilayer Coil Sheathed Nitinol-Based FNA Needle: Review of Five Cases, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.