Percutaneous and endoscopic ultrasound (EUS)-guided fine needle aspirations have been used widely in the diagnosis of intraabdominal lesions detected by imaging studies. These are safe, highly accurate, and minimally invasive techniques. Because FNA diagnosis also can aid in the selection of the type of therapy (surgical vs. nonsurgical) in some cases, high accuracy is critical. This can be achieved by teamwork between the radiologist (or other physician performing the FNA) and the pathologist. Collection of adequate specimens, proper preparation of the material, and the pathologist's experience are obvious factors in reaching the correct diagnosis.A\In Fine Needle Aspirations of Liver, Kidney and Adrenal Glands, the percutaneous approach is usually used. In recent literature, however, EUS-guided FNAs of these organs have been reported. The first chapter of the book, written by radiologists Dr. Stephanie Coquia and Dr. Ulrike M. Hamper, presents key clinical and technical features of image guidance methods for FNA of intraabdominal masses and organs. On-site evaluation, discussed in the second chapter, assures that adequate specimens are obtained and determines whether the specimen should be sent for special studies, e.g., flow cytometry. In the organ-specific chapters, although emphasis is on the cytomorphology of the lesions, additional studies, such as immunohistochemical stains in cell blocks or core biopsies, are presented as needed for the specific diagnosis.A\This book is meant to be a practical guide for the diagnosis of lesions, mostly neoplasms, of liver, kidney, and adrenal glands. We believe that the cytopathologic diagnosis of malignancy should be made cautiously after careful examination of the material, and it should be as accurate as a tissue diagnosis. Baltimore, MD, USA: Yener S. Erozan, M.D.; Baton Rouge, LA, USA: Armanda Tatsas, M.D.

1 Image-Guided Fine Needle Aspiration of Infra-abdominal Masses and Organs:Liver, Kidney, and Adrenal Gland 1

Indications 1

Contraindications 2

Complications 2

Patient Preparation 3

Image Guidance Methods 3

      Ultrasound Guidance 4

      CT Guidance 5

      Endoscopic Guidance 5

Biopsy Technique 7

      Needle Selection and Visualization 8

On-site Pathologic Evaluation 9

Specific Anatomic Applications 9

      Liver 9

      Kidney 10

      Adrenal Gland 10

Other Issues 13

Conclusions 13

Suggested Reading 13

2 On-Site Evaluation and Specimen Preparation 15

Suggested Reading 16

3 Liver 17

Introduction 17

Approach 17

Sensitivity, Specificity, and Accuracy 19

Complications 19

Contraindications 19

Normal Components of Liver 20

      Hepatocytes 20

      Biliary Ductal Epithelium 22

      Endothelial Cells 24

      Kupffer Cells 24

Contaminants 24

      Mesothelial Cells 24

      Gastric Wall 25

      Pulmonary/Respiratory Epithelium 25

      Skeletal Muscle and Skin 26

Pigments (Table 3.2) 26

      Lipofuscin 26

      Bile 27

      Hemosiderin 27

      Melanin 28

Nonneoplastic Processes and Benign Nodules 28

      Infections 28

Extramedullary Hematopoiesis 32

Hemangioma 34

Cirrhosis 36

Regenerative or Dysplastic Nodules 39

      Macroregenerative Nodules 39

      Dysplastic Nodules 40

Focal Nodular Hyperplasia (FNH) 40

Hepatic (Liver Cell) Adenoma 42

Bile Duct Adenoma 43

Angiomyolipoma 44

Hepatobiliary Cystadenoma 44

Primary Hepatic Malignant Neoplasms 45

      Hepatocellular Carcinoma (HCC) 45

Special Types of Hepatocellular Carcinoma 55

      Fibrolamellar HCC 55

      Intrahepatic Cholangiocarcinoma 62

      Combined HCC/Cholangiocarcinoma 65

Rare Primary Malignant Neoplasms 65

      Hematopoietic Malignancies 65

      Hepatoblastoma 66

      Undifferentiated (Embryonal) Sarcoma 71

      Angiosarcoma 71

      Epithelioid Hemangioendothelioma 74

Metastatic Neoplasms to Liver 75

      Metastatic Carcinomas 75

      Metastatic Neuroendocrine Tumors 87

      Metastatic Malignant Melanoma 91

      Metastatic Spindle Cell Neoplasms 94

      Metastatic Hematopoietic Neoplasms 95

Suggested Reading 99

      Contraindications 99

      Pigments 99

      Hepatobiliary Cystadenoma 99

      Rare Primary Malignant Neoplasms 100

      Metastatic Neoplasms to Liver 101

4 Biliary Tract 103

Specimen Procurement and Preparation 103

Benign/Normal Biliary Epithelium 104

Reactive Biliary Epithelium 104

Infectious Organisms 108

Cholangiocarcinoma 109

Suggested Reading 113

5 Kidney 115

Introduction 115

Normal Components 115

Nonneoplastic Masses and Cystic Lesions 117

      Xanthogranulomatous Pyelonephritis (XGP) 117

      Abscess 118

      Benign Cysts 119

      Extramedullary Hematopoiesis (EMH) 120

Benign Neoplasms 121

      Oncocytoma 121

      Angiomyolipoma 123

      Metanephric Adenoma 124

Malignant Neoplasms 125

Renal Cell Carcinomas (RCCs) 125

      Grading of RCC 126

      Accuracy of FNA in the Diagnosis of RCCs 128

Clear Cell (Conventional) Renal Cell Carcinoma (CRCC) 128

Papillary Renal Cell Carcinoma (PRCC) 131

Chromophobe Renal Cell Carcinoma 135

Collecting Duct Carcinoma (CDC) 138

Medullary Renal Cell Carcinoma (MRCC) 139

Mucinous Tubular and Spindle Cell Carcinoma 141

Renal Cell Carcinoma with Xp11.2 Translocation 142

Unclassified RCC 144

Sarcomatoid RCC 144

Metastatic Neoplasms 145

Urothelial Carcinoma of Renal Pelvis 146

Nephroblastoma (Wilms Tumor) 150

Rhabdoid Tumor 152

Suggested Reading 154

      General 154

      Adequacy and Accuracy 155

      Benign Lesions 155

      Renal Cell Carcinomas 156

      Small Round Cell Tumors 158

      Hematopoietic Lesions 159

      Immunohistochemistry 160

      Molecular/Genetic Studies 160

      Rhabdoid Tumor 161

      Urothelial Carcinoma of Kidney Pelvis 161

      Metastatic Neoplasms 161

6 Adrenal Glands 163

Introduction 163

      Fine Needle Aspiration (FNA) 163

Cysts 164

Nodular Cortical Hyperplasia and Cortical Adenoma 164

Myelolipoma 166

Pheochromocytoma 168

Adrenocortical Carcinoma 170

Neuroblastoma 173

Metastatic Neoplasms 175

Suggested Reading 179

      General: FNA 179

      EUS-Guided FNA 179

      Adrenal Cysts 180

      Myelolipoma 180

      Pheochromocytoma 180

      Adrenocortical Carcinoma 180

Index 183

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