Table of Contents

1 Image-Guided Fine Needle Aspiration
of Intra-abdominal Masses and Organs:
Liver, Kidney, and Adrenal Gland ............................... 1
Stephanie F. Coquia and Ulrike M. Hamper
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