A 64-year-old female patient with a 30-pack-year smoking history was admitted to the outpatient clinic for analyses of a hilar and mediastinal lymphadenopathy. Her past medical history revealed a follicular NHL stage IVa diagnosed in 2003. This disease presented with iliac lymphadenopathy and bone marrow localisation. She was initially treated with palliative radiotherapy for lymphoma in the left iliac area. In 2007, there was clinical evidence of disease progression based on palpable lymph nodes in the right iliac and the left-sided supraclavicular areas. A computed tomography (CT) of the abdomen also showed para-aortal lymphadenopathy. She underwent palliative radiotherapy on the right iliac lymphoma to treat its symptomatic mass effect. In September 2008, she was admitted for dyspnoea and a loss of appetite and a subsequent CT scan of the thorax, neck, and abdomen was performed. The CT scan revealed massive left hilar lymphadenopathy with compression of the surrounding bronchial and venous structures and mediastinal (subcarinal) and parasternal lymphadenopathy with a small left sided pleural effusion. A subsequent positron emission tomography (PET) scan showed multifocal disease activity in the pathological areas corresponding to the previous CT scan and low disease activity in the para-aortal region. Nonetheless, despite these extensive radiological investigations it was not possible to differentiate between progression of NHL or another disease pathology such as an underlying primary lung carcinoma. 
Accordingly, a bronchoscopy was performed that showed a slightly oedematous bronchial mucosa in the left lower lobe. Brushing, bronchial lavage and endobronchial biopsies of the oedematous mucosa with a transbronchial needle aspiration (TBNA) of the subcarinal node and a pleuracentesis were performed. Further sampling of the left sternal mass with transthoracic FNA was also conducted but all these tests failed to deliver a diagnosis. 
Therefore, it was deemed necessary to perform an EUS-FNA with material being obtained from the subcarinal lymphoma location 7 and from the possible primary process. Both aspirations delivered macroscopic "worm-like" material. From this material, there were small tissue fragments on which the pathologist was able to perform histological analysis and immunohistochemical tests clearly showing localisation of the follicular lymphoma. 
EUS was performed according to published guidelines with an Olympus EUS EXERA ultrasonic video gastroscope GF-UC160P-OL5. After identification of the suspected lymph node, the FNA needle was introduced (model Olympus NA-200H-8022 needle width 22 Gauge). Following infiltration of the node, the mandarin was pulled back and in excess of 15 passes into the lymph node were performed before the needle was finally retracted. The mandarin was reintroduced to push any collected tissue fragments, that possessed a "worm-like" appearance, into a cytorich red (CRR) medium. Finally, after the mandarin was removed again, the remaining droplets were collected on glasses by clearing the needle with air, using a 20cc syringe.
This procedure resulted in the collection of:
"Worm-like" coherent material in the CRR, 
Air dried smeared droplets on glasses, and 
Cytospin fluid after the "worm-like" material was extracted. 
 These materials were then processed and investigated as follows
Cytological examination was performed on II and III, using May Grunwald-Giemsa colouring and Shandon EZ Megafunnel (Thermo Fisher) method with Papanicolaou colouring, respectively.
The "worm-like" fragments in CRR (I) were added to liquid agar, compressed on the bottom of a mold and left for solidification. The solidified agar was then taken out from the mold and encased in a cassette. The cassette was further processed according to routine histological investigative techniques. The following day, two slices were made at two different levels allowing standard and supplemental histological and immunohistochemical staining to be performed.
Our approach represents a subtle but significant adaptation to the routine handling of this material as a smear is not made from the "worm-like" fragment. By using our modified technique, we can generate two important advantages; firstly, it allows optimal use of the collected material including histological investigation. Secondly, it leads to a reduction in processing time owing to a reduction in the number of smears that are made. 
We opted to collect the material in CRR and not directly in formalin solution for the following reasons: firstly, due to the characteristics of CRR (fixation, haemolysis, denaturation of proteins, and compatibility with immunohistochemical staining), a specimen of superior quality could be obtained. Secondly, cytological examination could be performed on the diagnostic material in the CRR, after the "worms" were removed, using the Shandon EZ Megafunnel. This process is particularly advantageous as it is both quick and the equipment is relatively simple to use. Conversely, using an alternative formalin solution would have made the process markedly more complicated. 
However, it should be noted that in our aforementioned example, the cytological material referred to in II and III did not contribute to the diagnosis of lymphoma. Nonetheless, histological tissue fragments that were intact and possessed structural integrity, as illustrated in Figures 1, 2, and 3, were obtained from step I coherent material in CRR. Therefore, a subsequent diagnosis of follicular non-Hodgkin lymphoma could be made after immunohistochemical staining.