Role of endoscopic ultrasound fine-needle aspiration evaluating adrenal gland enlargement or mass

Table 1 Patients characteristics and endoscopic ultrasound findings n (%)

Characteristics	Diagnostic(n = 85)		Non-diagnostic(n = 9)	P value
	Benign(n = 60)	Malignant(n = 25)
Age (mean ± SD)	67 ± 11	63 ± 14		0.161
	66 ± 12		66 ± 11	0.992
Race
White	57 (95)	25 (100)	7 (78)
African American	3 (5)	0 (0)	2 (22)
Hispanic	0 (0)	0 (0)	0 (0)
Gender				≥ 0.993
Male	26 (27)	19 (20)	5 (5)
Female	34 (36)	6 (7)	4 (5)
Adrenal biopsied				≥ 0.994
Left	58 (61)	23 (24)	9 (10)
Right	2 (2)	3 (3)	0 (0)
EUS image of adrenal
Mass	49 (52)	25 (26)	6 (6)	0.145
Diffuse enlargement	11 (12)	1 (1)	3 (3)	0.096
Size by EUS, cm
Mean ± SD	3.4 ± 1.6	2.6 ± 1.2		0.0277
Mean ± SD	2.8 ± 1.4		2.4 ± 1.2	0.418
Range	0.7-5.2	1.3-7.0	1.0-4.0
Echogenicity
Hypoechoic	40 (42)	22 (24)	4 (4)
Hyperechoic	1 (1)	0 (0)	1 (1)	0.149
Not reported or unavailable	19 (20)	4 (4)	4 (4)
Number of FNA passes
Mean ± SD	3.0 ± 1.7	3.0 ± 1.3	3.1 ± 1.5	0.461

¹Mean age diagnostic vs non-diagnostic;

²Diagnostic vs non-diagnostic cytology result based on gender;

³Adrenal Gland FNA side and Diagnostic vs non-diagnostic cytology result;

⁴Presence or absence of an adrenal mass and diagnostic vs non-diagnostic cytology result;

⁵Presence of absence of an adrenal mass and benign vs malignant FNA cytology;

⁶Median size by EUS (cm) and malignant vs benign FNA cytology;

⁷Median size by EUS (cm) and Diagnostic vs non-diagnostic cytology;

⁸Adrenal Echogenicity on EUS and Diagnostic vs non-diagnostic cytology;

⁹Number of FNA passes; and Diagnostic vs non-diagnostic FNA; ¹⁰Mean age benign vs malignant. EUS: Endoscopic ultrasound; FNA: Fine-needle aspiration.

Table 2 Indications for endoscopic ultrasound

Indication for EUS	n (%)
Cancer staging1	26 (27)
Suspected cancer recurrence2	5 (6)
Abnormal CT/PET-CT or MRI
Pancreatic mass	20 (21)
Mediastinal mass	10 (11)
Lung mass	7 (7)
Adrenal mass	7(7)
Gastric mass	2 (2)
Liver mass	3 (3)
Kidney mass	1 (1)
Retroperitoneal mass	1 (1)
Other3	12 (13)
Total of patients	94

¹Esophageal cancer (n = 3), gastric cancer (n = 2), breast (n = 1), jejunal adenocarcinoma (n = 1), renal cell cancer (n = 2), cholangiocarcinoma (n = 1), lung cancer (n = 16); ²Suspected recurrence of oral cancer (n = 1), breast cancer (n = 1), hepatoma (n = 1), lung adenocarcinoma (n = 1), esophageal adenocarcinoma (n = 1);

³Chronic pancreatitis (n = 3), abnormal upper endoscopy (n = 3), common bile duct stricture (n = 2), celiac nerve block (n = 1), suspected metastatic disease on imaging (n = 1), Barrett’s esophagus with high grade dysplasia (n = 1), ectatic pancreatic duct (n = 1). EUS: Endoscopic ultrasound; PET: Positron emission tomography; CT: Computed tomography.

Table 3 Previous diagnosis of cancer in patients undergoing endoscopic ultrasound guided fine-needle aspiration

Previous diagnosis ofcancer (n = 40)	Benign cytology on EUS-FNA(n = 21)	Malignant cytology on EUS-FNA(n = 15)	Non-diagnostic cytology onEUS-FNA(n = 4)
Penile cancer	0	1	0
Oral SCC	0	1	0
Lung cancer	15	3	1
Renal cell carcinoma	0	2	1
Esophageal ADC	1	3	0
Breast cancer	1	1	0
Gastric ADC	1	1	0
Hepatocellular carcinoma	0	1	0
Pulmonary carcinoid	0	0	1
Colon ADC	0	1	1
SCC of the duodenum	1	0	0
Basal cell cancer of the skin	1	0	0
Bladder cancer	1	0	0
Melanoma	0	1	0

EUS-FNA: Endoscopic ultrasound guided fine-needle aspiration; SCC: Squamous cell carcinoma; ADC: Adenocarcinoma.

Table 4 Timing of diagnostic and non-diagnostic biopsies n (%)

Timing ofEUS-FNA	DiagnosticEUS-FNA	Non diagnostic EUS-FNA	TotalEUS-FNA
Before 01/2004	31 (33)	6 (7)	37
After 2004	54 (57)	3 (3)	57
Total	85 (90)	9 (10)	94

Non diagnostic EUS-FNA before 2004 vs after 2004 (P = NS). EUS-FNA: Endoscopic ultrasound guided fine-needle aspiration.

Table 5 Cytology results from adrenal gland endoscopic ultrasound guided fine-needle aspiration

EUS-FNA cytologic diagnosis
Malignant EUS-FNA cytology (26%, n = 25)
Metastatic lung cancer
Metastatic esophageal adenocarcinoma
Metastatic colon adenocarcinoma
Metastatic renal cell carcinoma
Metastatic breast adenocarcinoma
Metastatic pancreatic adenocarcinoma
Metastatic melanoma
Metastatic oral squamous cell carcinoma
Metastatic hepatocellular carcinoma
Undifferentiated carcinoma
Benign EUS-FNA cytology (64%, n = 60)
Benign adrenal tissue
Aldosteronoma
Paraganglioma
Pheochromocytoma1

¹Previously negative normal plasma catecholamines and, 24-h urine normetanephrines, vanillylmandelic acid and metanephrines. EUS-FNA: Endoscopic ultrasound guided fine-needle aspiration.

Table 6 Final diagnosis for patients with non-malignant biopsies for who follow up was available

Final diagnosis	Benign FNA	Non-diagnostic FNA
Confirmed benign on follow up	321	51
Confirmed malignant on follow up	42	0
Total of patients with follow up	36	5

¹Follow up CT;

²Subsequent CT-guided adrenal biopsy (n = 2), enlargement on repeat CT (n = 1) or adrenalectomy (n = 1). FNA: Fine-needle aspiration; CT: Computed tomography.

Table 7 Comparison of different Studies evaluating adrenal gland endoscopic ultrasound guided fine-needle aspiration

Ref.	Year	Number of patients	Patient population	EUS-FNA Left adrenal, n	Patient population	EUS-FNA Left adrenal, n	EUS-FNA Right adrenal, n	Benign EUS-FNA cytology, n	Malignant EUS-FNA cytology (n)	Non-Diagnostic rate	Sensitivity	Specificity	PPV	NPV	F/U for benign lesions	Method for F/U
Current research	2014	94	Patients undergoing EUS-FNA of either adrenal	94	Patients undergoing EUS-FNA of either adrenal	90	5	60	25	10%	86%	97%	96%	89%	Available on 36/60	CT/MRI, repeat EUS at ≥ 6 mo or surgical pathology from adrenalectomy
1Uemura et al[13]	2013	150	Potentially resectable lung cancer	150	Potentially resectable lung cancer	91	51	7	4	0%	100%	100%	100%	100%	Available in 4/7	F/U CT at 6 months
Schuurbiers et al[17]	2011	85	Lung cancer	150	Lung cancer	85	0	25	55	6%	86%	96%	91%	70%	Available in 23/30	Clinical (n = 11) or F/U CT (n = 10)2
Eloubeidi et al[12]	2010	59	Known or suspected malignancy	59	Known or suspected malignancy	54	5	37	22	0%	NR	NR	NR	NR	Clinical F/U for 37	Not part of study protocol
Bodtger et al[4]	2009	40	Known or suspected lung cancer	40	Known or suspected lung cancer	40	0	29	11	0%	94%	43%	91%	55%	Available	Survival at 2 yr

¹EUS-FNA was done in 11 patients, 3 had bilateral EUS-FNA;

²Two patients had CT at 3 mo. EUS-FNA: Endoscopic ultrasound guided fine-needle aspiration; PPV: Positive predictive value; NPV: Negative predictive value; FNA: Fine-needle aspiration; F/U: Follow up; N/A: Not available; NR: Not reported; CT: Computerized Tomography.