THE AMERICAN JOURNAL OF GASTROENTEROLOGY
9, 2003
© 2003 by Am. Coll. of Gastroenterology
Published by Elsevier Inc.
Endoscopic Ultrasound–Guided Fine Needle
Aspiration Cytology of Solid Liver Lesions:
A Large Single-Center Experience
John DeWitt, M.D., Julia LeBlanc, M.D., Lee McHenry, M.D., Dan Ciaccia, M.D., Tom Imperiale, M.D.,
John Chappo, B.S., C.T., Harvey Cramer, M.D., Kathy McGreevy, R.N., Melissa Chriswell, R.N., and
Stuart Sherman, M.D.
Department of Gastroenterology and Hepatology and Department of Pathology and Laboratory Medicine,
Indiana University Medical Center, Indianapolis, Indiana
OBJECTIVES: The aim of this study was to report the sen-
sitivity, cytological diagnoses, endoscopic ultrasound (EUS)
features, complications, clinical impact, and long term fol-
low-up of a large single-center experience with endoscopic
ultrasound– guided fine needle aspiration (EUS-FNA) of
benign and malignant solid liver lesions.
METHODS: A database of cytologic specimens from EUS-
FNA was reviewed to identify all hepatic lesions aspirated
between January, 1997, and July, 2002. Procedural indica-
tions, prior radiographic data, patient demographics, EUS
examination results, complications, and follow-up data were
obtained and recorded.
RESULTS: EUS-FNA of 77 liver lesions in 77 patients was
performed without complications. Of these 77 lesions, 45
(58%) were diagnostic for malignancy, 25 (33%) were be-
nign, and seven (9%) were nondiagnostic. A total of 22
lesions were confirmed as negative for malignancy by fol-
low-up (mean 762 days, range 512–1556 days) or intraop-
erative examination; however, seven lesions could not be
classified as benign or malignant. Depending on the status of
the seven unclassified lesions, sensitivity of EUS-FNA for
the diagnosis of malignancy ranged from 82 to 94%. When
compared with benign lesions, EUS features predictive of
malignant hepatic masses were the presence of regular outer
margins (60% vs 27%; p ⫽ 0.02) and the detection of two
or more lesions (38% vs 9%; p ⫽ 0.03). Of the 42 patients
with malignancy identified by EUS-FNA and other avail-
able imaging records, EUS detected the malignancy in 41%
of patients with previously negative examinations. For the
45 subjects with cytology positive for malignancy, EUS-
FNA changed management in 86% of subjects.
CONCLUSION: EUS-FNA of the liver is a safe and sensitive
procedure that can have a significant impact on patient
management. Prospective studies comparing the accuracy
and complication rate of EUS-FNA and percutaneous fine
needle aspiration (P-FNA) for the diagnosis of liver tumors
are needed. (Am J Gastroenterol 2003;98:1976 –1981. ©
2003 by Am. Coll. of Gastroenterology)
Vol. 98, No.
ISSN 0002-9270/03/$30.00
doi:10.1016/S0002-9270(03)00549-5
INTRODUCTION
Identification of hepatic metastases from systemic malig-
nancy usually implies inoperable disease and a poor prog-
nosis. Furthermore, the diagnosis of unresectable malig-
nancy may obviate the need for surgery along with its
inherent morbidity and mortality. The diagnosis of liver
masses is traditionally accomplished by percutaneous fine
needle aspiration (P-FNA) under fluoroscopic, computed
tomographic, or ultrasonographic guidance (1–3). Although
rare, complications from P-FNA may include severe bleed-
ing and implantation metastases in up to 3% of patients
(3– 8).
Endoscopic ultrasound (EUS)– guided fine needle aspira-
tion (EUS-FNA) has been established as a safe and accurate
method for the diagnosis of benign or malignant lymphad-
enopathy and for intramural and extramural neoplasms (9,
10). The role of EUS-FNA in the diagnosis and staging of
liver metastases or masses, however, is limited to a small
single-center series (11), a large retrospective international
survey (12), and several case series (13, 14). Furthermore,
the sensitivity of EUS-FNA and endosonographic features
of benign and malignant hepatic lesions have not been
described. The aim of this study was to report the sensitivity,
cytological diagnoses, EUS features, complications, and
clinical impact of a large single-center experience with
EUS-FNA of solid liver lesions.
MATERIALS AND METHODS
From an existing EUS-FNA cytology database, we identi-
fied all patients between January, 1997, and July, 2002, in
whom EUS-FNA of the liver was performed. The database
used had been maintained and prospectively updated by one
cytotechnologist (J.C.). Patients with hilar cholangiocarci-
nomas or cystic hepatic lesions were excluded from the
analysis.
Staging EUS examinations for known or suspected ma-
lignancy were performed initially with an Olympus GF-
UM20 or GFUM-130 radial echoendoscope (Olympus,
AJG – September, 2003 EUS-FNA Cytology of Solid Liver Lesions 1977

Melville NY). The right lobe of the liver was surveyed from Table 1. Indications for EUS Examinations by Cytology Results of
the duodenum and distal stomach, whereas the left lobe was EUS-FNA of the Liver
imaged from the proximal and mid-stomach. Endoscope Cytology Result
rotation was used as necessary to visualize as much of the All Malignant Benign/ND
liver parenchyma as possible. EUS-FNA was performed Indication (n ⫽ 77) (n ⫽ 45) (n ⫽ 32)
using the Pentax 32-UA, Pentax 36-UX (Pentax Precision Abnormal ERCP 21 (27) 11 (24) 10 (31)
Instruments, Orangeburg, NY), Olympus GF-UC30P, or Pancreatic mass on CT 19 (25) 12 (27) 7 (22)
Olympus GF-UC140P curvilinear array echoendoscope. Staging of known cancer 10 (13) 7 (16) 3 (9)
EUS-FNA was performed using a 22-gauge, 8-cm Wilson- Liver mass on CT 9 (12) 9 (20) 0 (0)
Other abnormal CT findings 4 (5) 1 (2) 3 (9)
Cook EUSN-1, EUSN-2, or EUSN-3 needle (Wilson-Cook Suspected recurrent cancer 2 (3) 1 (2) 1 (3)
Medical, Winston-Salem, NC) by one of four physicians Chronic abdominal pain 2 (3) 0 (0) 2 (7)
(J.D., D.C., L.M., or J.L.). Doppler color angiography was Other 10 (12) 4 (9) 6 (19)
used to ensure the absence of intervening vascular structures Total 77 45 32
along the anticipated needle path. Depending on the amount ND ⫽ nondiagnostic
of blood anticipated during tissue sampling, full, partial, or
no suction was applied at the discretion of the endoscopist,
cytotechnologist, or cytopathologist. A cytotechnologist or staged primary malignancy); 4) incurred no change in man-
cytopathologist was available on-site for preliminary inter- agement (results did not change patient treatment). This
pretations on all procedures. Samples aspirated were ex- study was approved by the Institutional Review Board at our
pressed onto a glass slide and two smear preparations were institution.
made. One slide was air-dried and stained with a modified
Giemsa stain for rapid on-site interpretation. The other slide Statistical Analysis
was alcohol-fixed and stained by the Papanicolaou method. Assuming that the EUS-FNA diagnosis of malignancy is a
EUS-FNA was repeated until a definitive diagnosis was true positive, sensitivity was calculated as the proportion of
made or the endoscopist believed that further sampling patients with cancer in whom EUS-FNA was positive for
would not likely increase yield. Within several days of each malignancy. For analysis, continuous variables were de-
EUS examination, a final cytological diagnosis was ren- scribed as means and standard deviations, and dichotomous
dered by a staff cytopathologist. variables were expressed as simple proportions with or
A true positive EUS-FNA for malignancy is defined as without 95% confidence limits. Student’s t test and ␹2 or
unequivocal cytological evidence of malignancy. A false Fisher’s exact tests were used to test for differences in
negative aspirate is a nondiagnostic or benign specimen, comparisons between continuous and dichotomous vari-
which is subsequently found to be malignant by percutane- ables, respectively.
ous FNA or intraoperative findings. A true negative EUS-
FNA for malignancy is defined as benign or nondiagnostic RESULTS
samples that are either confirmed as benign by alternative
sampling, intraoperative examination, or appropriate clini- In total, EUS-FNA was performed on 77 different liver
cal follow-up. Specimens with benign hepatocytes without lesions in 77 patients (42 male and 35 female, 69 white and
evidence of atypical cells are categorized as benign aspi- eight African American, with a mean age of 63 ⫾ 11 yr).
rates. Aspirates from EUS-FNA that are interpreted as non- Follow-up was available in all patients.
diagnostic, highly suspicious, suspicious, or atypical for Indications for EUS Examinations
malignancy are considered as negative for malignancy. The indications for the 77 EUS procedures are recorded in
Medical records of enrolled subjects were reviewed and Table 1. The two most common indications were abnormal
procedural indications, prior radiographic data, patient de- ERCP findings, the majority of which were strictures, and a
mographics, EUS test results, clinical outcomes, procedural pancreatic mass on CT scan, which accounted for 27% and
complications, and follow-up data were abstracted. When 25% of the procedures performed, respectively. Ten (13%)
multiple liver lesions were noted, the endosonographic de- of 77 procedures were done for staging of a recently diag-
scription of only the aspirated lesion was recorded. When nosed malignancy (pancreas in five, esophageal in four, and
charts were incomplete, written informed consent was sent lung in one). Of the 45 malignancies diagnosed by EUS-
and follow-up telephone calls were made to the subject, FNA, the most common indications for the EUS were a CT
closest relative of the deceased, or referring physician for finding of a pancreatic mass (27%) and abnormal ERCP
clarification or any required further information. The poten- findings (24%).
tial clinical impact of EUS-FNA of a liver metastasis or
malignancy is defined as results that met the following Characteristics of EUS Examination
criteria: 1) avoided surgery (results precluded resectable EUS-FNA was performed in 77 patients (mean 3.4 ⫾ 1.8
malignancy); 2) made diagnosis (results provided initial passes, range 1– 8) into the left lobe (n ⫽ 66; 86%) and right
diagnosis of malignancy); 3) upstaged tumor (results up- lobe (n ⫽ 11; 14%) of the liver without procedural compli-
1978 DeWitt et al. AJG – Vol. 98, No. 9, 2003

Table 2. Characteristics of EUS Examination

All* Malignant† Benign‡
(n ⫽ 77) (n ⫽ 48) (n ⫽ 22) p-value§
Site of FNA
Left lobe 66 (86) 41 (85) 20 (91) 0.57
Right lobe 11 (14) 7 (15) 2 (9)
No. of passes 3.4 ⫾ 1.8 3.5 ⫾ 1.5 3.2 ⫾ 1.5 0.44
Range 1–8 1–8 1–8
Echogenicity
Hypoechoic 52 (68) 33 (69) 13 (59) 0.36
Hyperechoic 23 (30) 13 (27) 9 (41)
Both 2 (2) 2 (4) 0 (0)
Margins
Regular 39 (51) 29 (60) 6 (27) 0.02
Irregular 38 (49) 19 (40) 16 (73)
Size (mm) 16.0 ⫾ 10.8 15.6 ⫾ 7.7 16.7 ⫾ 12.0 0.70
Range 3–40 3–35 4–40
No. of lesions seen
1 57 (74) 30 (62) 20 (91) 0.03
⬎1 20 (26) 18 (38) 2 (9)
* Includes seven patients unable to be classified as benign or malignant.
† Includes 45 positive and three false negative EUS-FNA results.
‡ By follow-up or intraoperative findings.
§ Between malignant and benign lesions.
Figure 1. Sensitivity of EUS-FNA of the liver for the diagnosis of
malignancy.
cations (upper 95% CI ⫽ 4.7%; see Table 2). A total of 45
(58%) aspirates were diagnostic for malignancy. Three false or echotexture (p ⫽ 0.36). Malignant masses, however,
negatives were later discovered by intraoperative findings (n were more often accompanied by the presence of multiple
⫽ 2) or P-FNA (n ⫽ 1). One patient with pancreatic ade- hepatic lesions detected on EUS (38% vs 9%; p ⫽ 0.03; ␹2
nocarcinoma (as confirmed by EUS-FNA of the pancreas) analysis) and to have regular margins (60% vs 27%; p ⫽
had benign cytology of a 6-mm left lobe mass that intraop- 0.02; ␹2 analysis).
eratively was confirmed as metastatic adenocarcinoma. A
second patient with pancreatic adenocarcinoma (as con- Diagnoses from EUS-FNA of the Liver
firmed by EUS-FNA of the pancreas) had benign cytology The final diagnoses for the 45 malignant liver aspirates are
of a 6-mm right lobe mass, which was later confirmed by recorded in Table 3. Of these, 44 (98%) were metastatic and
percutaneous ultrasound-guided biopsy as metastatic adeno- one (2%) was a hepatocellular carcinoma. The most com-
carcinoma. The third patient with a false negative EUS-FNA mon diagnosis was metastatic adenocarcinoma from the
had a 29-mm left lobe mass that was benign by EUS-FNA. pancreas, which accounted for 34 of 45 (76%). The next
Intraoperative examination, however, confirmed hepatocel- most frequent diagnosis was metastatic neuroendocrine tu-
lular carcinoma. Overall, 48 of 77 (62%) of the liver masses mor from the pancreas (n ⫽ 5; 11%). Of the 32 nonmalig-
were malignant. Among the remaining 29 subjects with nant aspirates, 25 (33%) were cytologically benign and
nonmalignant aspirates, in 22 (76%) the masses were con- seven (9%) were nondiagnostic. One (4%) benign aspirate
sidered benign by clinical follow-up (n ⫽ 18; mean 762 demonstrated cytological features consistent with an
days; range: 512–1556 days) or intraoperative evaluation (n abscess.
⫽ 4). Seven (24%) of the subjects with nonmalignant Previous Imaging of Malignancy Diagnosed by
masses with pancreatic adenocarcinoma (as confirmed by EUS-FNA
EUS-FNA of the pancreas; n ⫽ 6) or lung cancer (n ⫽ 1) Prior radiographic imaging reports were available for 42 of
died (mean 154 days, range 14 – 424 days) without fol- 45 (93%) malignant hepatic masses diagnosed by EUS-
low-up imaging, biopsy of the liver, or autopsy and there-
fore cannot be classified as benign or malignant. The 45 Table 3. Diagnoses of Malignant Aspirates of the Liver
diagnostic aspirates for malignancy are considered true pos-
Diagnosis No. (%)
itives (Fig. 1). Assuming that the test results for these seven
patients were all true negatives or all false negatives, the Pancreatic adenocarcinoma 34 (76)
Pancreatic neuroendocrine tumor 5 (11)
sensitivity of EUS-FNA for the diagnosis of malignancy
Renal cell carcinoma 2 (5)
would range from 82 to 94%. Gallbladder adenocarcinoma 1 (2)
In comparison between benign and malignant lesions Colon cancer 1 (2)
detected by EUS-FNA (Table 2), no statistically significant Hepatocellular carcinoma 1 (2)
difference was found between the liver lobe aspirated (p ⫽ Esophageal adenocarcinoma 1 (2)
Total 45
0.57), number of passes (p ⫽ 0.44), lesion size (p ⫽ 0.70),
AJG – September, 2003
FNA. All imaging had been performed within 45 days of the
EUS examination. Of these 42 lesions, EUS-FNA detected
malignancy in 17 (41%) when prior imaging of the liver by
CT alone (n ⫽ 13), transabdominal ultrasound (US) alone (n
⫽ 1), or both (n ⫽ 3) were normal. For the 32 patients in
whom CT alone was performed, EUS-FNA initially de-
tected a malignancy in 13 (41%). For the nine patients in
whom CT and US were both performed, EUS-FNA initially
detected malignancy in three (33%). The mean size of the 17
malignant liver lesions detected initially by EUS-FNA was
12.6 mm (range 3–26 mm). Of these 17, six (35%) were ⬍1
cm in diameter.
Clinical Impact of EUS-FNA of the Liver
For the 45 patients with malignant cytology, EUS-FNA had
(by protocol definition) a clinical impact in all patients.
EUS-FNA changed management, however, in only 38
(84%) of these patients, because in seven cases (16%) tumor
was upstaged but did not change overall patient manage-
ment. EUS-FNA provided the initial diagnosis of malig-
nancy in 35 patients (78%) and avoided surgery in 12
(27%). Of the 35 patients in whom EUS-FNA made the
initial diagnosis of malignancy, 34 (97%) had metastases
and one (3%) had a hepatocellular carcinoma. In 25 patients
(55%), the FNA provided both the primary diagnosis and
upstaged the malignancy. In nine subjects (20%), EUS-FNA
made the initial diagnosis, upstaged the tumor, and pre-
vented surgery. Three EUS-FNAs (7%) were diagnostic in
which previous CT-FNA was benign (two of three) or
nondiagnostic (one of three). In three patients with nonma-
lignant EUS-FNA aspirates, malignancy was later con-
firmed by surgery (n ⫽ 2) or percutaneous biopsy (n ⫽ 1).
Follow-Up After EUS-FNA
Of the 45 patients with malignant cytology from EUS-FNA,
40 have died, with a mean time to death after EUS-FNA of
135 days (range 7–754 days). The patient who died 7 days
after EUS-FNA expired in his sleep outside the hospital
without any apparent adverse consequence from EUS-FNA;
however, no autopsy was performed. The patient who lived
754 days had metastatic pancreatic cancer and enrolled in an
experimental chemotherapy protocol at another institution.
The longest survival otherwise was 298 days. Five patients
remain alive with a mean follow-up of 64 days (range
30 –140 days). The mean time to death from metastatic
pancreatic adenocarcinoma to the liver was 113 days (n ⫽
31; range 7–754 days).
DISCUSSION
The results of this study demonstrate that EUS-guided FNA
of solid hepatic masses is sensitive, safe, and has a signif-
icant impact on patient management when malignancy is
diagnosed. In our series, the sensitivity of EUS-FNA for the
diagnosis of malignancy ranged from 82% to 94%. Al-
though it may be presumed that we obtained no false pos-
EUS-FNA Cytology of Solid Liver Lesions 1979
itive results when testing aspirates, the inability to histolog-
ically corroborate this does not allow for calculation of
specificity. A previous report of 14 patients that underwent
EUS-FNA of liver metastases described a sensitivity and
specificity of 100% and 100% for the diagnosis of malig-
nancy (11). To our knowledge, however, our study is the
first report of the test characteristics of EUS-FNA of the
liver that includes both malignant and benign hepatic le-
sions. The sensitivity of the EUS-FNA of the liver we report
is similar to previous series that describe the sensitivity of
EUS-FNA of pancreatic malignancy (9, 15–17) and P-FNA
of liver tumors (2, 18 –20). Despite the good sensitivity of
EUS-FNA of liver tumors, we obtained three false negative
results. Therefore, follow-up percutaneous biopsy or intra-
operative evaluation is warranted when the diagnosis of
malignancy in the liver is strongly suspected and would
significantly affect patient management.
The mean number of overall passes performed for the
diagnosis of hepatic lesions (n ⫽ 3.2; range 1– 8) is slightly
higher in our series than has been previously reported (11).
The exact reason for this difference is not clear, although it
is not significantly different from the number required for
ultrasound-guided P-FNA of small hepatic masses (21). In a
series of 14 patients with EUS-FNA of a malignant liver
lesion, Nguyen et al. reported a mean of 2.0 (range 1–5)
passes for the diagnosis of malignancy (11). The presence of
a cytopathologist on-site was implied, as interpretation of
specimens was performed before making repeated passes.
We also have a cytotechnologist or cytopathologist avail-
able on site to assess the adequacy of obtained specimens.
Because the diagnosis of metastatic disease is clinically
relevant and initial air-dried preparations are sometimes
difficult to interpret, we will often repeat another pass to
ensure that cytology is sufficient to render a diagnosis if the
adequacy of a specimen is initially interpreted as “suspi-
cious” but not diagnostic of malignancy. We found no
statistically significant difference between the numbers of
passes required for the diagnosis of benign (n ⫽ 3.2; range
1– 8) or malignant (n ⫽ 3.5; range 1– 8) lesions. In addition,
no difference existed between the number of passes required
during the first or second half of the study. This implies that
increased experience with this technique may not decrease
the number of passes needed to obtain an accurate cytolog-
ical diagnosis.
Despite the relatively higher number of passes performed
in this study, we observed no complications after EUS-FNA
of the liver. In a large international survey of 167 cases
describing EUS-FNA of the liver, however, six complica-
tions (4%) were described (12). These complications in-
cluded one death in a patient who underwent EUS-FNA of
the liver despite a suspected obstructed biliary stent. Other
complications noted were bleeding, abdominal pain, and
fever. Although it is standard practice for gastroenterolo-
gists to observe patients in the right lateral decubitus posi-
tion for several hours after percutaneous biopsy of the liver,
we discharge stable patients within 60 –75 min after EUS-
1980 DeWitt et al.
FNA of the liver. Furthermore, we do not routinely place
patients on their right side during recovery before discharge.
A recent series (5) describing the use of P-FNA in the
diagnosis of 216 liver tumors reported the occurrence of
implantation metastases in seven patients (3%) a median 4
months (range 2– 49 months) after P-FNA of liver masses
from colorectal cancer (n ⫽ 5), gallbladder carcinoma (n ⫽
1), and a hepatoma (n ⫽ 1). In addition, the implantation
metastases caused major problems locally and were fatal in
four patients. This complication has not been described after
EUS-FNA of the liver. The true incidence of implantation
metastases after EUS-FNA of the liver, however, is difficult
to estimate, inasmuch as hepatic metastases from pancreatic
malignancy (which comprise 87% of malignancies in our
study) usually carry a dismal prognosis and are managed
nonoperatively. Therefore, as the overwhelming majority of
patients diagnosed with of hepatic metastases after EUS-
FNA of the liver do not undergo intended curative resection,
the true incidence of this complication is not known. The
most common malignancies diagnosed by P-FNA (colorec-
tal metastases and primary hepatomas) are often managed
surgically with curative intent. We believe that these fun-
damental differences partially explain the disparity in re-
ported incidence of implantation metastases between EUS-
FNA and P-FNA of liver masses. Studies comparing the
diagnostic accuracy and complications EUS-FNA and P-
FNA of all types of suspected liver tumors are needed to
resolve these issues.
The overall sensitivity of transabominal US for the de-
tection of liver metastases is reportedly between 80% and
90% (22, 23). Recent studies using helical CT and magnetic
resonance imaging, however, show that noninvasive imag-
ing is relatively insensitive for lesions ⬍1 cm (24 –26). By
EUS and EUS-FNA, we detected 17 malignant hepatic
lesions (mean 12.6 mm, range 3–26 mm) with a previously
normal CT alone (n ⫽ 13), CT and US (n ⫽ 3), or US alone
(n ⫽ 1). Of these, six (35%) were ⬍1 cm in diameter. These
17 lesions were found in 41% of the 42 patients with
available radiographic imaging information performed be-
fore EUS. Nguyen et al. (11) reported that CT performed
before EUS-FNA of the liver failed to detect liver lesions in
11 of 14 patients (79%). Collectively, these results demon-
strate the utility of EUS-FNA for the detection of malignant
liver lesions that have been missed by prior radiographic
imaging. Further comparative studies are needed to deter-
mine whether other imaging modalities such as fluorine-18
fluorodeoxyglucose positron emission tomography (27),
magnetic resonance imaging (28), harmonic ultrasound im-
aging (29), or ultrasound contrast agents (30) offer any
advantages over EUS for detection of occult or subcentime-
ter liver metastases.
When compared with benign lesions, we found that ma-
lignant lesions detected by EUS-FNA of the liver were more
likely to have regular margins (60% vs 27%; p ⫽ 0.02) and
to be accompanied by at least one other lesion detected on
EUS (38% vs 9%; p ⫽ 0.03). Furthermore, no statistically
AJG – Vol. 98, No. 9, 2003
significant difference was found with regard to site of biopsy
(p ⫽ 0.57), size (p ⫽ 0.70), echogenicity (p ⫽ 0.36), or
number of passes performed (p ⫽ 0.44) for these lesions.
Although EUS features of malignant lymphadenopathy have
been described (31), to our knowledge the endosonographic
features for malignant liver lesions have not been previously
reported. These findings may help to guide decision making
and assessment of the risk/benefit ratio of EUS-FNA of
hepatic masses.
In conclusion, the results of our study show that the
sensitivity of EUS-FNA of the liver for the diagnosis of
malignancy ranges from 82% to 94% and that, contrary to
previous reports, it is a safe procedure. When malignancy is
diagnosed, EUS-FNA of the liver significantly affects pa-
tient management and implies a poor overall prognosis.
EUS features predictive of malignant hepatic masses are the
presence of regular outer margins and the detection of two
or more lesions. In this series, EUS and EUS-FNA detected
malignant liver tumors that were not seen by CT or US (or
both) in 41% of subjects. Therefore, surveillance of the
entire liver is indicated during evaluation of known or
suspected malignancy. Prospective studies are needed to
compare the accuracy and complication rate of EUS-FNA
and P-FNA for the diagnosis of liver tumors.
Reprint requests and correspondence: John M. DeWitt, M.D.,
Department of Medicine, Division of Gastroenterology, Indiana
University Medical Center, 550 N. University Boulevard, UH
4100, Indianapolis, IN 46202-5121.
Received Nov. 11, 2002; accepted Jan. 30, 2003.
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