|Year : 2022 | Volume
| Issue : 2 | Page : 55-57
EUS guided tissue acquisition from the retroperitoneal mass, reason to caution – Case report and review
Shankar Zanwar1, Kamyani Deshpande2, Ravisagar Patel3
1 Department of Gastroenterology, Care Hospitals, Nagpur, Maharashtra, India
2 Department of Pathology, Institute of Surgical Pathology, Nagpur, Maharashtra, India
3 Department of Vascular Surgery, Maitreya Hospital, Surat, Gujarat, India
|Date of Submission||24-Jan-2022|
|Date of Acceptance||08-Feb-2022|
|Date of Web Publication||23-Mar-2022|
CARE Hospitals, Nagpur, Maharashtra
Source of Support: None, Conflict of Interest: None
We recently encountered an unexpected immediate complication while doing an endoscopic ultrasound-guided fine-needle biopsy in a patient with a retroperitoneal abdominal mass lesion found on cross-sectional imaging. The case is presented and the literature reviewed. The endosonologist should be prepared for eventualities after puncture for retroperitoneal masses.
Keywords: Endosonography, paraganglioma, retroperitoneal mass
|How to cite this article:|
Zanwar S, Deshpande K, Patel R. EUS guided tissue acquisition from the retroperitoneal mass, reason to caution – Case report and review. Gastroenterol Hepatol Endosc Pract 2022;2:55-7
|How to cite this URL:|
Zanwar S, Deshpande K, Patel R. EUS guided tissue acquisition from the retroperitoneal mass, reason to caution – Case report and review. Gastroenterol Hepatol Endosc Pract [serial online] 2022 [cited 2022 May 24];2:55-7. Available from: http://www.ghepjournal.com/text.asp?2022/2/2/55/340390
| Introduction|| |
Masses in retro peritoneum are a heterogeneous group of lesions which are uncommon and are a challenge in diagnosis due to overlapping features in imaging. They do not have fixed age predilection though cases are commoner in adulthood. Of the malignant group of retroperitoneal masses nearly 75% are mesenchymal in origin.
Retroperitoneal masses are divided into, primary which do not originate from organs like kidney, adrenals, pancreas or bowel loops and are further divided into solid and cystic group which is based on radiological findings. They further can be divided as infective, inflammatory and neoplastic. Further elaborate description of the masses is out of the scope for this review.
Preoperative diagnosis is essential to decide the plan of management. Infective masses without compressive symptoms as with tuberculosis can be managed medical. While malignant resectable masses need upfront surgery.
We here have summarized our experience of a one such similar cases which as an unusual encounter during endosonography guided tissue acquisition.
| Case Report|| |
A 34-year-old female came with a complaint of pain in the abdomen for 6 months. The pain was diffuse and dull aching and moderate in intensity, intermittent, unrelated to meals or position, non-radiating with no history of altered bowel, nausea, vomiting, loss of appetite, weight, fever, significant personal or family history. Her general and systemic examination was unremarkable.
A review of investigations done at her place revealed the presence of a mass in the abdomen detected on sonography. Contrast computerized tomogram (CT) done at a local hospital showed an enhancing mass lesion anterior to inferior vena cava (IVC) which was measuring 30 mm × 22 mm in size; the possibility of precaval enlarged lymph node was suggested. At our place, hemogram and liver and renal parameters were normal. HIV serology was negative. After noting this mass in CT, she was enquired for personal or family history of tuberculosis and B symptoms and none were found. The radiologist reviewed images and suggested percutaneous CT-guided/sonography-guided access would be risky in view of intervening bowel loops and very close proximity to the great vessels. Thus, endosonography-guided access was planned.
Endosonography (EUS) using linear echoendoscope (Olympus ME-2) was done. A mass lesion was seen below the lower margin of the pancreas of size 28 mm × 34 mm [Figure 1]. The margins were well defined, and it was anterior to the IVC. The lesion appeared grossly hypoechoic with foci of anechoic areas. No significant vascularity was noted, and there were no calcifications seen. This lesion appeared separated from the duodenal wall. Impression from the EUS imaging was of retroperitoneal mass with differentials as – large lymph node – tubercular/lymphoma/metastatic from unknown primary. Other differentials considered were extraintestinal gastrointestinal stromal tumor/retroperitoneal fibroma. Fine-needle aspiration biopsy was done with a 22G Boston Scientific “Acquire” needle. Two passes were made and the sample was sent for cytology, and tissue cores were sent for histology and GeneXpert Mycobacterium tuberculosis nucleic acid amplification test.
Just after the needle puncture into the mass, the heart rate and blood pressure of the patient increased markedly to 130 beats and 180/100 mmHg, respectively. Intravenous labetalol had to be given to lower this down. There was no visible bleed. The possibility of needle puncture to nearby ganglion was suspected.
Cytology and histopathology report was suggestive of cells with round nuclei, mild anisonucleosis, and abundant eosinophilic cytoplasm [Figure 2]. These features were consistent with paraganglioma. Immunohistochemistry of the sample tissue was done, and the cells were positive for synaptophysin and chromogranin. The above event of the rise in heart and blood pressure was thus explainable.
The patient was advised further evaluation and needed for surgery, but she was reluctant due to COVID-19 pandemic times and absence of symptoms. In the month of February 2021, she was re-evaluated, urinary catecholamines were raised, metaiodobenzylguanidine scan [Figure 3] was positive for uptake in only the retroperitoneal area as in the CT scan, and other synchronous lesions were excluded. After adequate alpha- and beta-blockade, she underwent surgery. Intraoperatively [Figure 4], the tumor was located anterior to IVC and was also abutting the aorta. Post procedure, she had an uneventful course and was discharged asymptomatic. She planned for biochemical and radiological follow-up after 6 months.
| Discussion|| |
EUS-guided tissue acquisition was first described in 1992 by Peter Vilmann et al. Years have passed and the needles and imaging have progressively refined our practice of cytology to biopsies using endosonography guidance. In a review by Mizuide et al., EUS-fine-needle aspiration (FNA)-related complications have ranged from 0 to 2.5% and mortality rates around 0%–0.8%. These data of complications and mortality are suggestive of fairly safe outcomes of EUS needle aspirations. Nevertheless, complications as described in our case should be kept in mind while dealing with retroperitoneal masses.
Paragangliomas are rare neuroendocrine tumors; they are pheochromocytomas situated outside the adrenal glands. Among all the paragangliomas – 84% are found in the abdomen, 30%–50% are malignant, 36%–60% are functional, i.e., they secrete noradrenaline and normetanephrine and amongst those secreting these catecholamines nearly 10%–14% are asymptomatic.
To the best of our knowledge, based on English language Medical Subject Headings in search engines and PubMed to find retroperitoneal paraganglioma and EUS-FNA, there are very limited (only 5) studies,,,, in the published literature. This is the first case report from India. All of them had found this diagnosis serendipitously. In these studies [Table 1] of EUS-guided tissue acquisition – all patients were adult females, in 3 out of 5 studies, the patient developed severe hypertension after needle puncture. One had not mentioned any event after needle puncture, and in one Japanese study, hypertension developed during surgery.
|Table 1: Compilation of published studies on retroperitoneal paraganglioma found on endosonography|
Click here to view
Even though EUS-FNA from a suspected paraganglioma for tissue diagnosis is debatable, it is prudent to establish the biochemical and nuclear imaging-guided diagnosis beforehand to prevent avoidable complications. If the patient has symptoms consistent with a paraganglioma or a cystic mass of uncertain etiology, it is advisable to assay a 24-h urine collection for catecholamines, metanephrine, and vanillylmandelic acid before needle puncturing of the lesion. Although EUS-FNA is risky, assessment of anatomically adjacent structures by EUS may provide useful information before surgical resection. EUS-FNA could be useful in nonsecreting tumors where the above biochemical tests are inconclusive.
In conclusion, we present the first case of EUS-guided FNA of paraganglioma from India. With this case, we highlight the consideration of differential diagnosis of paraganglioma in retroperitoneal masses and the need of caution before EUS-guided puncture.
Consent was obtained from the patient regarding the use of her medical information for publication.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
We would like to thank Dr. Amit Agrawal (DM – Gastroenterology), Disha Clinic, Nagpur, for providing EUS setup.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]