Endoscopic ultrasound (EUS) and EUS-guided fine-needle

aspiration (FNA) of liver lesions

Phuong Nguyen, MD, Jack C. Feng, MD, Kenneth J. Chang, MD
Orange, California

Background: Endoscopic ultrasonography (EUS) is not traditionally thought to be clinically applic-

able in liver imaging. EUS-guided fine-needle aspiration of the liver has not been well described.
Methods: A prospective study was conducted in which 574 consecutive patients with a his-
tory or suspicion of gastrointestinal or pulmonary malignant tumor undergoing upper EUS
examinations underwent EUS evaluation of the liver. Fourteen (2.4%) patients were found to
have focal liver lesions and underwent EUS-guided fine-needle aspiration.
Results: The median largest diameter of the liver lesions was 1.1 cm (range 0.8 to 5.2 cm). The
mean number of passes was 2.0 (range 1 to 5 passes). All fine-needle passes yielded an ade-
quate specimen. One of the 14 patients underwent EUS-guided fine-needle aspiration of 2
liver lesions. Fourteen of the 15 liver lesions sampled by means of EUS-guided fine-needle
aspiration were malignant and one was benign. Before EUS, computed tomography (CT)
depicted liver lesions in only 3 of 14 (21%) patients. Seven of 14 patients had a known cancer
diagnosis. For the other 7, the initial diagnosis of cancer was made by means of EUS-guided
fine-needle aspiration of the liver. There were no immediate or late complications.
Conclusions: EUS can detect small focal liver lesions that are not detected at CT. Findings of
EUS-guided fine-needle aspiration can confirm a cytologic diagnosis of liver metastasis and
establish a definitive M stage that may change clinical management. (Gastrointest Endosc
1999;50:357-61.)

EUS has assumed an important role in the diag-
nosis and staging of malignant GI tumors over the
past few decades. The addition of EUS-guided fine-
needle aspiration (FNA) has increased the diagnostic
and staging accuracy over EUS alone.1 The clinical
utility of EUS and EUS-guided FNA appears to be
greatest in the diagnosis and staging of pancreatic
cancer and in the staging of malignant tumors of the
esophagus.2-7 EUS, however, is not traditionally
thought to be applicable in the detection of liver
metastases. The role of EUS-guided FNA in diag-
nosing liver lesions has not been well described. We
report on a series of patients with liver lesions
detected by means of EUS with subsequent EUS-
guided FNA.
PATIENTS AND METHODS
The liver was evaluated for a series of 574 consecutive
patients (April 1, 1995, through February 12, 1998) under-
going upper EUS for various indications (diagnosis and
Received June 10, 1998. For revision September 17, 1998. Accepted
January 14, 1999.
From the Division of Gastroenterology, University of California,
Irvine Medical Center, Orange, California.
Presented in abstract form at the American Society of
Gastrointestinal Endoscopy EUS Topic Forum, May 11-14, 1997,
Washington, DC, (Gastrointest Endosc 1997;45:AB176).
Reprint requests: Phuong Nguyen, MD, UCI Clinical Cancer
Center, 101 The City Drive, Bldg 23, Rt 81, Orange, CA 92868.
Copyright © 1999 by the American Society for Gastrointestinal
Endoscopy 0016-5107/99/$8.00 + 0 37/1/97208
staging of malignant GI or pulmonary tumors). Fourteen
(10 men, 4 women, age range 38 to 88 years) of the 574
patients had focal solid liver lesions (5 right lobe, 9 left
lobe) and underwent EUS-guided FNA. Among these 14
patients, the indications for EUS before FNA included a
pancreatic lesion seen at CT without a tissue diagnosis
(6), established pancreatic cancer with referral for EUS
staging (3), liver mass with referral to assess primary
lesion and establish tissue diagnosis (2), staging of
esophageal cancer (1), diagnosis of extrinsic esophageal
compression (1), and duodenal mass (1). All procedures
were performed by one of two endosonographers (K.J.C.,
P. N.). Informed consent was obtained under protocols
approved by our institutional review board (UCI HS 94-
02, 94-03). Platelet count and prothrombin time were
obtained for all patients before the procedure. Exclusion
criteria included cystic or vascular lesions, prothrombin
time greater than 15 seconds, and platelet count less than
50,000. Antibiotics were not given prophylactically.
All 574 patients were first examined with a mechanical
radial scanning echoendoscope at 7.5 MHz (GF-UM3 or
UM20; Olympus America, Inc. Melville, N.Y.). EUS was
performed in a sequential manner similar to transabdom-
inal US in which the order of structures examined was the
same for each patient. The left lobe and hilum of the liver
were examined from the gastric body and fundus after
other surrounding structures were seen. The tip of the
echoendoscope was placed in the gastric antrum, the bal-
loon inflated with 5 to 10 mL of water, and suction applied
to remove intragastric air. The echoendoscope was then
slowly withdrawn with a right turn and the scope tip
deflected up (similar to the shortening technique for
ERCP). When the liver came into view, the instrument

VOLUME 50, NO. 3, 1999 GASTROINTESTINAL ENDOSCOPY 357

P Nguyen, J Feng, K Chang
was rotated to evaluate all portions of the liver. The right
lobe of the liver was imaged from the duodenum and
antrum. The best location for viewing the right lobe is
from the duodenal bulb. When liver parenchyma is identi-
fied, the transducer is rotated to visualize all portions.
When a liver lesion was found, a linear array echoen-
doscope (FG-32UA or FG-36UX; Pentax, Orangeburg,
N.Y.) was used for FNA. The linear array echoendoscope (5
and 7.5 MHz) also was used to examine the livers of all
patients who had no detectable focal liver lesion during
examination with the radial scanning echoendoscope. All
15 lesions were imaged by means of both radial scanning
and linear array echoendoscopy. The vascularity of the
region was assessed with the linear array echoendoscope
with color flow mapping and Doppler US of both the lesion
and surrounding structures. EUS-guided FNA was per-
formed as previously described.1 A 22-gauge 10 cm needle
was used for FNA (GIP; Mediglobe, Tempe, Arizona). After
each FNA pass, preliminary cytologic assessment of the
specimen was performed before another pass was made.
Clinical outcome was categorized as no change (results
of EUS FNA made no difference in clinical management),
avoided surgery (results prevented unnecessary surgical
intervention), upstaged tumor (results led to upstaging of
primary malignant tumor), or made diagnosis (results led
to a diagnosis of malignant tumor).
RESULTS
EUS disclosed focal liver lesions in 14 of 574
(2.4%) patients. Multiple lesions were found in 7 of
14 patients (range 1 to 30 lesions). All liver lesions
imaged with EUS in our series were round with reg-
ular borders. With color flow mapping and Doppler
US, the lesions had no internal vascular structures.
The median largest diameter of the liver lesions was
1.1 cm and the mean 1.8 cm (range 0.8 to 5.2 cm).
Twelve of the 15 lesions detected by EUS and that
had FNA were less than 2 cm in diameter. The most
difficult portions of the liver to visualize were near
the dome of the diaphragm and the inferior portions
of the right lobe of the liver.
EUS-guided FNA was performed on a total of 15
liver lesions in the 14 patients (Table 1). One patient
underwent FNA of two separate liver lesions
because FNA of the first lesion in this patient yielded
normal preliminary cytologic results. The final cyto-
logic diagnosis of both lesions was adenocarcinoma.
In these patients, the average needle distance from
the gastric or duodenal wall to the liver lesion was
3.3 cm (range 2.2 to 5.0 cm). The mean number of
passes per lesion was 2.0 (range 1 to 5 passes). EUS-
guided FNA yielded an adequate specimen in all 14
patients. Fourteen of the 15 lesions sampled by
means of EUS-guided FNA were found to be malig-
nant (11 adenocarcinoma, 1 squamous cell carcinoma,
2 poorly differentiated carcinoma). One patient with
pancreatic cancer and one liver lesion had an EUS-
358 GASTROINTESTINAL ENDOSCOPY
EUS and EUS-guided fine-needle aspiration of liver lesions
guided FNA cytologic diagnosis of benign hepato-
cytes. At autopsy, no liver metastasis was detected.
There were no immediate or late complications of
EUS-guided FNA with a mean follow-up period of
5.5 months (range 1 to 23 months).
Conventional abdominal CT performed before
EUS depicted focal lesions in only 3 of the 14
patients. The average time interval between CT and
EUS was 35 days (range 3 to 93 days). In most
patients CT was performed within 2 months of the
EUS procedure. The mean largest size of the lesions
detected at CT in these 3 patients was 3.5 cm (range
1.0 to 5.2 cm). One patient underwent CT-guided
FNA of the liver lesion whereas two patients did not.
CT-guided FNA yielded reactive hepatocytes and no
malignant cells in this patient, and EUS-guided
FNA gave the tissue diagnosis of adenocarcinoma.
Seven of 14 patients had a known cancer diagnosis
before EUS. For the other 7, the initial diagnosis of
cancer was made by means of EUS-guided FNA of
the liver. EUS-guided FNA confirmed the diagnosis
of liver metastasis (stage M1) and avoided surgery
for 7 of the 14 patients (Table 2).
DISCUSSION
The diagnosis of liver metastasis is important stag-
ing information for deciding on therapy. Trans-
abdominal US and contrast-enhanced CT are the
most commonly used imaging methods for evaluating
liver metastases. EUS and EUS-guided FNA have
been shown to be efficacious in the diagnosis and stag-
ing of pancreatic cancer and in the nodal staging of
malignant GI and pulmonary tumors.1-7 However,
EUS has not had a clinical role in imaging the liver.
CT has been found to have an overall sensitivity of
68% for the detection of focal liver lesions in patients
with malignant disease.8 However, for lesions less than
1 cm in diameter, the detection rate drops to 49%.8 In
our study, EUS disclosed liver lesions in 13 patients
with a median size of 1.1 cm and a mean size of 1.8 cm;
12 of the 15 lesions seen with EUS were smaller than
2 cm. CT detected lesions in only 3 patients (21%).
Spiral CT with arterial portography is a newer tech-
nique that has mini-mal motion artifact and section
misregistration, thus it provides enhanced visualiza-
tion of the liver.9-11 However, this modality frequently
shows nontumorous perfusion defects and therefore
has a high false-positive rate of diagnosis.9-12
Transabdominal US has an overall detection rate
for liver metastases ranging from 53% to 71%.8,13-15
For liver lesions smaller than 1 cm in diameter, the
detection rate falls to 20%.8 This modality appears
to be inferior to CT and magnetic resonance imaging
(MRI) for detecting liver metastases.8,16-18 MRI has
been shown to be superior to CT for detecting hepat-
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EUS and EUS-guided fine-needle aspiration of liver lesions P Nguyen, J Feng, K Chang

Table 1. EUS findings in patients undergoing EUS-guided FNA of the liver

Distance from
No. of gastric duodenal
Patient CT Tumor Largest No. of FNA wall to liver Primary
No. detection echotexture size (cm) lesions passes lesion (cm) cancer Cell type
1 No Hypoechoic 0.9 3 2 2.7 Pancreatic carcinoma Adenocarcinoma
2 No Hypoechoic 1.9 1 1 N/A* Lung carcinoma Adenocarcinoma
3 No Hypoechoic 1.1 1 3 3.8 Pancreatic carcinoma Adenocarcinoma
4 No Hypoechoic 1.3 3 1 2.2 Pancreatic carcinoma Adenocarcinoma
5 Yes Hypoechoic 1.0 30 1 4.1 Pancreatic carcinoma Adenocarcinoma
6 No Hypoechoic 1.0 3 5 3.0 Esophageal carcinoma Squamous cell
carcinoma
7 No Hypoechoic 1.1 3 3 2.4 Pancreatic carcinoma Adenocarcinoma
8 No Hypoechoic 1.2 1 2 2.7 Pancreatic carcinoma Adenocarcinoma
9 Yes Hyperechoic 4.3 1 3 5.0 Cholangiocarcinoma Adenocarcinoma
10 No Hypoechoic 0.8 1 1 2.5 Pancreatic carcinoma Adenocarcinoma
11 Yes Hypoechoic 5.2 3 3 2.3 Hepatoma Poorly different-
iated carcinoma
12 No Hypoechoic 4.0 1 1 3.0 Breast carcinoma Adenocarcinoma
13 No Hypoechoic 1.1 4 4 5.0 Lung carcinoma Poorly different-
iated carcinoma
14 No Hyperechoic 1.1 1 1 4.3 Pancreatic carcinoma Benign

*Not measured.

ic lesions in some comparative studies and inferior
in others.8,19,20 The conflicting results may relate to
variations in contrast enhancement techniques and
the many different MRI pulse sequences.21
EUS has been used to detect pancreatic cancer with
high sensitivities, ranging from 88% to 99%.4,22-24 For
lymph node staging of gastric and esophageal cancer,
EUS sensitivities are similarly high, reported ranges
being 74% to 80% and 80% to 90%, respectively.25
However, to our knowledge there have been no series
reported on the utility of EUS or EUS-guided FNA for
detecting liver lesions. In our series, EUS revealed
that 14 of a group of 574 patients undergoing EUS for
various indications had focal liver lesions; convention-
al CT missed focal liver lesions in 11 of these patients.
Because patients with obvious liver metastasis at CT
were not referred for EUS local staging, EUS may
have greater utility in the detection of liver metasta-
sis before CT.
Various sonographic patterns and echo character-
istics of liver lesions have been described with trans-
abdominal US. Tumors with high vascularity such as
renal cell and islet cell carcinoma tend to appear
hyperechoic.26,27 Hypovascular lesions, such as lym-
phoma, appear as hypoechoic lesions.28,29 We identi-
fied 12 patients with hypoechoic and 2 with hypere-
choic liver lesions (Figs. 1 and 2; Table 1). One of the
hyperechoic lesions yielded benign hepatocytes at
FNA, and the other was a cholangiocarcinoma.
For the 14 liver lesions detected with EUS,
EUS-guided FNA had a sensitivity, specificity, and
diagnostic accuracy of 100%. In comparison, CT
and US-guided FNA have been reported to have
sensitivities ranging from 83% to 93.2%. 30-33
Table 2. Clinical outcome with EUS-guided FNA
of the liver
Outcome No. of patients Primary malignant lesion
No change 1/14 (7%) Pancreatic (1)
Avoided surgery 7/14 (50%) Pancreatic (5), lung (1),
esophageal (1)
Upstaged tumor 4/7 (57%) Pancreatic (2), breast (1),
lung (1)
Made diagnosis 7/7 (100%) Pancreatic (5), hepatoma
(1), cholangiocarcinoma (1)
However, percutaneous FNA is limited by inability
to depict small focal liver lesions. In our series, CT
showed liver lesions in only 3 of 14 patients (21%)
with liver lesions imaged with EUS. Although 2 of
the 3 patients did not undergo percutaneous FNA,
1 patient did undergo CT-guided FNA of the liver
with cytologic findings that revealed no malignant
cells. A diagnosis of adenocarcinoma was made for
this patient on the basis of EUS-guided FNA find-
ings (Fig. 3).
In our experience, EUS-guided FNA of liver
lesions located far away from the tip of the echoen-
doscope was often more difficult than FNA of lesions
closer to the probe. The needle may bend or curve as
it traverses normal liver to reach the target liver
lesion. The needle tip may then miss the target if the
lesion is small. When this occurred, minor adjust-
ments were needed in the needle trajectory to comp-
ensate for the bend in the needle. Liver lesions near
the second or third portion of the duodenum were
difficult to visualize, likely because of positioning of
the echoendoscope. In our series, the mean number
of passes per lesion was two, which is in the range of

VOLUME 50, NO. 3, 1999 GASTROINTESTINAL ENDOSCOPY 359

P Nguyen, J Feng, K Chang
Figure 1. EUS image of a 1 cm hypoechoic lesion in the left
lobe of the liver not detected with CT.
Figure 2. EUS image of a 1.2 cm hyperechoic lesion not
detected with CT.
EUS-guided FNA of lymph nodes in published series.
This number is far less than the mean number of
passes required for FNA of a pancreatic lesion.24
There were no immediate or late complications in
our series of 14 patients who underwent EUS-guided
FNA of the liver. In rare instances percutaneous
FNA of the liver has been associated with tumor
seeding, intrahepatic hematoma, and hemor-
rhage.34-38 EUS-guided FNA has the possible
advantage over the percutaneous route of shorter
insertion length of the needle if the liver lesion is
360 GASTROINTESTINAL ENDOSCOPY
EUS and EUS-guided fine-needle aspiration of liver lesions
Figure 3. Image from EUS-guided FNA with needle (arrow
indicates needle tip) aspiration from a hypoechoic liver lesion.
deep to the skin surface. With FNA by means of
EUS, there is continuous visualization of the needle
tip, which helps to minimize risk for bleeding when
the procedure is performed in conjunction with color
flow and Doppler US. Bleeding or hematoma imme-
diately after FNA may be detected during EUS. In
this series, no patients reported postprocedural
abdominal pain. All of the liver lesions in the series
were solid, and antibiotics were not given prophy-
lactically before FNA.
The utility of EUS and EUS-guided FNA of the
liver lies in the ability to make the initial cancer
diagnosis, upstage cancer, avoid surgery, and save
money. In our series, EUS-guided FNA of the liver
established the diagnosis of metastatic disease, and
7 of 14 patients avoided surgery. Seven patients had
a known diagnosis of cancer before EUS. For 4 of
these 7 patients, the tumor was upstaged on the
basis of the EUS-guided FNA diagnosis of metasta-
tic disease. For the other 7, the initial diagnosis of
cancer was made by means of EUS-guided FNA of
the liver; they were able to avoid additional diag-
nostic procedures.
Although EUS has not traditionally been used in
evaluation of the liver, in our series most of the liver
parenchyma was well imaged with EUS. It depicted
small focal liver lesions undetected with conventional
CT. With EUS-guided FNA, it is possible to make a
cytologic diagnosis of small liver metastasis and
establish the M stage, which may change clinical man-
agement. EUS imaging of the liver provides valuable
information and should be performed routinely on
patients undergoing EUS with known or suspected
cancer. Peripheral liver lesions, those far from the
probe of the echoendoscope, are not well visualized. A
prospective evaluation of the depth of penetration into
the liver at EUS-guided FNA will be useful.
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EUS and EUS-guided fine-needle aspiration of liver lesions
REFERENCES
1. Chang KJ, Katz KD, Durbin TE, Erickson RA, Butler JA, Lin
F, et al. Endoscopic ultrasound–guided fine-needle aspiration.
Gastrointest Endosc 1994;40:694-9.
2. Rösch T, Lorenz R, Braig C, Gain T, Feuerbach S, Siewert JR,
et al. Staging of pancreatic and ampullary carcinoma by
endoscopic ultrasonography: comparison with conventional
sonography, computed tomography, and angiography.
Gastroenterology 1992;102:188-99.
3. Rösch T, Lorenz R, Braig C, Classen M. Endoscopic ultra-
sonography in diagnosis and staging of pancreatic and biliary
tumors. Endoscopy 1992;24(Suppl):304-8.
4. Rösch T, Lorenz R, Braig C, Feuerbach S, Siewert JR,
Schusdziarra V, et al. Endoscopic ultrasound in pancreatic
tumor diagnosis. Gastrointest Endosc 1991;37:347-52.
5. Yasuda K, Mukai H, Fujimoto S, Nakajima M, Kawai K. The
diagnosis of pancreatic cancer by endoscopic ultrasonography.
Gastrointest Endosc 1988;34:1-8.
6. Kaufman AR, Sivak MV. Endoscopic ultrasonography in the
differential diagnosis of pancreatic disease. Gastrointest
Endosc 1989;35:214-9.
7. Ikeda M, Fujino M, Morozumi A, Sano S, Kinose T, Yamamoto
Y, et al. Diagnosis of small pancreatic tumor by endoscopic
ultrasonography [abstract]. Gastroenterology 1989;96:A225.
8. Wernecke K, Rummeny E, Bongartz G, Vassallo P, Kivelitz D,
Wiesmann W, et al. Detection of hepatic masses in patients
with carcinoma: comparative sensitivities of sonography, CT,
and MR imaging. AJR 1991;157:731-9.
9. Bluemke DA, Soyer PA, Chan BW, Bliss DF, Calhoun PS,
Fishman EK. Spiral CT during arterial portography: tech-
nique and applications. Radiographics 1995;15:623-39.
10. Bluemke DA, Urban B, Fishman EK. Spiral CT of the liver: cur-
rent applications. Semin Ultrasound CT MR 1994;15:107-21.
11. Bluemke DA, Fishman EK. Spiral CT of the abdomen: clini-
cal applications. Crit Rev Diagn Imaging 1993;34:103-57.
12. Lupetin AR, Cammisa BA, Beckman I, Dash N, Khoury MB,
Kiproff PM, et al. Spiral CT during arterial portography.
Radiographics 1996;16:723-46.
13. Scholmerich J, Volk BA, Gerok W. Value and limitations of
abdominal ultrasound in tumour staging: liver metastasis
and lymphoma. Eur J Radiol 1987;7:243-5.
14. Matsui O, Takashima T, Kadoya M, Suzuki M, Hirose J,
Kameyama T, et al. Liver metastases from colorectal cancers:
detection with CT during arterial portography. Radiology
1987;165:65-9.
15. Lundstedt C, Ekbert H, Hederstrom E, Stridbeck H, Torfason
B, Transberg KG, et al. Radiologic diagnosis of liver metas-
tases in colo-rectal carcinoma: prospective evaluation of the
accuracy of angiography, ultrasonography, computed tomog-
raphy and computed tomographic angiography. Acta Radiol
1987;28:431-8.
16. Schreve RH, Terpstra OT, Ausema L, Lameris JL, van Seijen
AJ, Jeekel J. Detection of liver metastases: a prospective
study comparing liver enzymes, scintigraphy, ultrasonogra-
phy and computed tomography. Br J Surg 1984;71:947-9.
17. Snow JH, Goldstein HM, Wallace S. Comparison of scintigra-
phy, sonography, and computed tomography in the evaluation
of hepatic neoplasms. AJR 1979;132:915-8.
18. Curati WL, Halevy A, Gibson RN, Carr DH, Blumgart LH,
Steiner RE. Ultrasound, CT, and MRI: comparison in prima-
ry and secondary tumors of the liver. Gastrointest Radiol
1988;13:123-8.
19. Hagspiel KD, Neidl KF, Eichenberger AC, Weder W, Marincek
B. Detection of liver metastases: comparison of superpara-
magnetic iron oxide-enhanced and unenhanced MR imaging
VOLUME 50, NO. 3, 1999
P Nguyen, J Feng, K Chang
at 1.5 T with dynamic CT, intraoperative US, and percuta-
neous US. Radiology 1995;196:471-8.
20. Soyer P, Levesque M, Caudron C, Elias D, Zeitoun G, Roche
A. MRI of liver metastases from colorectal cancer vs. CT dur-
ing arterial portography. J Comput Assist Tomogr 1993;
17:64-74.
21. Heiken JP, Weyman PJ, Lee JK, Balfe DM, Picus D, Brunt
EM, et al. Detection of focal hepatic masses: prospective eval-
uation with CT, delayed CT, CT during arterial portography,
and MR imaging. Radiology 1989;171:47-51.
22. Zimmer T, Ziegler K, Bader M, Fett U, Hamm B, Riecken EO,
et al. Localization of neuroendocrine tumours of the upper
gastrointestinal tract. Gut 1994;35:471-5.
23. Massari M, Cioffi U, De Simone M, Bonavina L, D’elia A,
Rosso L, et al. Endoscopic ultrasonography for preoperative
staging of gastric carcinoma. Hepatogastroenterol 1996;
43:542-6.
24. Chang KJ, Nguyen P, Erickson R, Durbin T, Katz K. The clin-
ical utility of endoscopic ultrasound-guided fine-needle aspi-
ration in the diagnosis and staging of pancreatic carcinoma.
Gastrointest Endosc 1997;45:387-93.
25. Nattermann C, Galbenu-Gmnwald R, Nier H, Dancygier H.
Endoscopic ultrasound in TN staging of stomach cancer: a
comparison with computerized tomography and conventional
ultrasound. Z Gesamte Inn Med 1993;48:60-4.
26. Tanaka S, Kitamura T, Imaoka S, Sasaki Y, Taniguchi H,
Ishiguro S. Hepatocellular carcinoma: sonographic and histo-
logic correlation. AJR 1983;140:701-7.
27. Rubaltelli L, Del Mashio A, Candiani F, Miotto D. The role of
vascularization in the formation of echographic patterns of
hepatic metastases: microangiographic and echographic
study. Br J Radiol 1980;53:1166-8.
28. Sanders LM, Botet JF, Straus DJ, Ryan J, Filippa DA,
Newhouse JH. Computed tomography of primary lymphoma
of the liver. AJR 1989;152:973-6.
29. Townsend RR, Laing F, Jeffrey RB, Bottles K. Abdominal lym-
phoma in AIDS: evaluation with ultrasound. Radiology
1989;171:719-24.
30. Edoute Y, Tibon-Fisher O, Ben Haim S, Malberger E.
Ultrasonically guided fine-needle aspiration of liver lesions.
Am J Gastroenterol 1992;87:1138-41.
31. Samaratunga H, Wright G. Value of fine needle aspiration
biopsy cytology in the diagnosis of discrete hepatic lesions
suspicious for malignancy. Aust N Z J Surg 1992;62:540-4.
32. Fornari F, Civardi G, Cavanna L, Rossi S, Buscarini E, Di
Stasi M, et al. Ultrasonically guided fine-needle aspiration
biopsy: a highly diagnostic procedure for hepatic tumors. Am
J Gastroenterol 1990;85:1009-13.
33. Sautereau D, Vireo O, Cazes PY, Cazals JB, Catanzano G,
Claude R, et al. Value of sonographically guided fine needle
aspiration biopsy in evaluating the liver with sonographic
abnormalities. Gastroenterology 1987;93:715-8.
34. Livraghi T, Damascelli B, Lombardi C, Spagnoli I. Risk in fine-
needle abdominal biopsy. J Clin Ultrasound 1983;11:77-81.
35. Edoute Y, Ben-Haim S, Brenner B, Malberger E. Fatal hemo-
peritoneum after fine-needle aspiration of a liver metastasis.
Am J Gastroenterol 1992;87:358-9.
36. Glaser KS, Weger AR, Schmid KW, Bodner E. Is fine-needle
aspiration of tumours harmless [editorial]? Lancet 1989;1:620.
37. Kowdley KV, Aggarwal A, Sachs PB. Delayed hemorrhage
after percutaneous liver biopsy: role of therapeutic angiogra-
phy. J Clin Gastroenterol 1994;19:50-3.
38. Vergara V, Garripoli A, Marucci MM, Bonino F, Capussotti L.
Colon cancer seeding after percutaneous fine needle aspira-
tion of liver metastasis. J Hepatol 1993;18:276-8.
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