Benchmarking cytology support for ROSE during endoscopic and bronchoscopic procedures

INTRODUCTION

There has been an increase in endoscopic and bronchoscopic biopsies as minimally invasive methods to obtain specimens from gastrointestinal (GI) or pancreatobiliary lesions and thoracic or mediastinal lesions, respectively. As hospitals undertake more of these procedures, it is important to consider the staffing implications that this has on cytopathology laboratories with respect to support for rapid on-site evaluation (ROSE).

MATERIALS AND METHODS

Volume and time data from endoscopic ultrasound and bronchoscopic procedures (including endobronchial ultrasound-guided transbronchial needle aspirations and small biopsies with touch preparation) in the GI suite, bronchoscopy suite, or operating room were reviewed for 2 months at 2 different medical centers with ROSE services provided by cytologists or fellows physically present at the procedure and cytopathologists located remotely using telecytology. Statistical analysis was performed to investigate significant trends based on the location of the biopsies and other factors.

RESULTS

A total of 16 proceduralists performed 159 procedures and submitted 276 different specimens during 16 total weeks at 2 institutions. The total ROSE time for the on-site personnel to cover these procedures was 109.3 hours (bronchoscopy, 62.3 hours [57%]; GI, 29.8 hours [27%]; OR, 17.2 hours [16%]), which represents an average of 0.69 hour (41.4 minutes) per procedure or 0.40 hour (24.0 minutes) per part, with the shortest procedure times per sample recorded during bronchoscopy. When stratified by practice volume for individual proceduralists, the average time per specimen sample submitted was shorter for proceduralists with high volume practices and was most pronounced during bronchoscopy procedures.

CONCLUSIONS

Endoscopic and bronchoscopic procedures account for an increasing amount of the ROSE time for the cytology team. On average, each ROSE procedure takes 0.69 hour (41.4 minutes) or approximately 0.40 hour (24.0 minutes) per specimen, with shorter time requirements for specimens obtained in bronchoscopy procedures and for operators with high volume practices for endobronchial ultrasound-guided transbronchial needle aspirations. This provides important benchmarking data to calculate staffing needs for cytology to provide ROSE support for different proceduralists.

Insufficient endobronchial ultrasound-guided transbronchial needle aspiration specimens. When and why? The analysis of criteria and reasons behind the insufficient specimens

BACKGROUND

The classification terminology systems for pulmonary cytology specimens have recently emerged. Inadequate samples, classified as "nondiagnostic," raise challenges in determining the threshold of cell numbers and the risk of malignancy (ROM).

METHODS

The study retrospectively reviewed 248 endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) samples: 46 insufficient samples, 60 low cellularity samples, and 142 adequate samples. Characteristics as cellularity, number of benign and malignant cells, and background features were assessed. Receiver operating characteristic curve analysis was performed to establish cell sufficiency thresholds for the diagnosis.

RESULTS

Out of the 248 samples analyzed, 108 were classified as benign, 94 as malignant, and 46 as insufficient. The study found that the cellularity thresholds for diagnosis in cell blocks and cytological samples were ≥50 cells and ≥100 cells, respectively. The thresholds for tumor cell counts were ≥1 - 10 cells for both types of cells, respectively. Considerably, some low cellularity samples were initially classified as insufficient despite meeting the diagnostic thresholds upon revision. The ROM varied across sample categories, with insufficient samples having a ROM of 10.9%, benign samples 15.7%, suspicious samples 92.0%, and malignant samples 100%.

CONCLUSION

Insufficient EBUS-TBNA samples raise challenges in diagnosis and management. This study identified the root cause of insufficient samples, including factors related to humans, diagnostic methods, sampling, and laboratory processing. By understanding the root causes, diagnostic recommendations can be developed to improve the diagnostic process. The findings emphasize the importance of standardized classification and terminology systems for clear communication among healthcare professionals and institutions, ultimately improving patient care and enabling quality assurance measures.

Retrospective application of WHO reporting system for lung cytopathology with assessment of risk of malignancy

INTRODUCTION

The recently introduced World Health Organization (WHO) Reporting System for Lung Cytopathology presents 5 diagnostic categories with corresponding risk of malignancy (ROM) and management protocols. This study uses the system to categorize our institutional respiratory tract cytology specimens, evaluating ROM and diagnostic accuracy for each category.

MATERIALS AND METHODS

In a retrospective analysis (May 2020 to August 2021), the following respiratory cytology specimens were classified based on the WHO categories: bronchoalveolar lavage (BAL), bronchial wash/bronchial brushings (BB/BW), endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), fine-needle aspiration cytology (FNAC), sputum, biopsy imprint (BI), and endotracheal wash. Exclusions comprised pleural effusions and EBUS-TBNA from mediastinal and hilar lymph nodes. Correlation of cytologic and histopathologic diagnoses was performed to assess ROM collectively and individually.

RESULTS

A total of 1518 respiratory samples (BAL [968], BW/BB [380], EBUS-TBNA [42], FNAC [32], sputum [80], BI [11] and endotracheal wash [5]) of 1410 patients were screened, of which 522 cases (34.3%) had histopathologic correlation. One hundred forty-one cases (9.3%) were Insufficient/Inadequate/Non-Diagnostic (ND), 1221 (80.4%) were Benign (B), 3 (0.2%) were Atypical (A), 32 (2.1%) were Suspicious for malignancy (SM) and 121 (8.0%) were Malignant (M). The estimated ROM for each category was 49.2% for ND, 13.3% for B, 66.6% for A, 81.5% for SM and 92.7% for M. FNAC and EBUS-TBNA exhibited the highest sensitivity (100%) compared with BW/BB (66.3%). Specificity ranged from 96.8% to 100% across the samples, while diagnostic accuracy varied from 58.8% to 100%.

CONCLUSIONS

Application of the WHO reporting system enhances standardized terminology, aiding clinicians in informed decision-making and improving patient care through accurate risk assessment of malignancy.

Risk of malignancy assessment of the different cytologic categories in respiratory cytology samples according to the new guidelines of the Papanicolaou Society of Cytopathology

BACKGROUND

Cytology is extremely important for diagnosis of lung carcinoma and the Papanicolaou Society of Cytopathology (PSC) had proposed a new classification system for respiratory cytology for better communication between physicians and better patient management. The objective of this study is to analyze our samples in accordance with this classification and to evaluate the diagnostic accuracy of various cytologic techniques and to assess the risk of malignancy.

METHODS

Eight hundred and twenty respiratory cytology specimens (FNA, BAL, washing, brushing, sputum) collected between 2019 and 2022 were classified according to the PSC system and the risk of malignancy was assessed for each category using follow-up surgical samples. Sensitivity, specificity, and accuracy rates were determined based on a categorial approach, according to a similar study.

RESULTS

The data of 820 respiratory cytology specimens from 576 patients were analyzed. 2.6% of these were non-diagnostic, 64.1% were NM, 5% were AC, 0.4% were N-B-LG, 4% were SM and 23.9% were ML. The risk of malignancy for each diagnostic category were: 42.8% for non-diagnostic, 31.2% for NM, 43.9% for AC, 87.9% for SM, 94.3% for ML. Sensitivity and specificity was calculated using only the malignant cases considered as positive tests and was 45.57% and 97.34% respectively.

CONCLUSION

Our results correlated with the PSC system, and it was considered useful in clinical practice. However, more studies should be performed to evaluate the usefulness of this system. The ROMs of each category and the impact of different techniques should be further studied.

Approach to Mediastinal Fine Needle Aspiration Cytology

Mediastinal fine needle aspirations are routinely encountered in cytopathology practice. Mediastinal lesions may pose diagnostic challenges owing to their rarity and locations associated with the complexity of the mediastinal anatomic structures in the thoracic cavity. Diagnosing mediastinal lesions and guiding patient management usually require correlating with clinical and radiologic findings, being familiar with cytomorphologic features and appropriately triaging the diagnostic material for ancillary testing. This review proposes a practical approach to interpret mediastinal fine needle aspirations and emphasizes potential diagnostic pitfalls for mediastinal lesions including benign cysts, thymic neoplasms, lymphoproliferative disorders, germ cell tumors, mesenchymal tumors, and metastatic tumors.

Useful on-site macroscopic quantitative evaluation of EBUS-TBNA samples

Background

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive diagnostic test with a high diagnostic yield. Optimal specimen acquisition is of a key importance; however, rapid on-site cytology examination (ROSE) during EBUS-TBNA has limited access. In an attempt to provide immediate feedback to the operator, the intervention pulmonology team started to classify macroscopically every lymph node sample in terms of abundance. The main objective of this study was to clarify whether this on-site macroscopic evaluation of EBUS sample was related to histology results and therefore any helpful for clinical practice.

Results

From a total of 288 lymph node stations sampled, adequate/diagnostic histological results were present in 11.1% of “insufficient” samples, 40.9% “sufficient” samples, 76.4% “good” samples and 88.1% of “excellent” samples. This was statistically significant with p-value under 0.0001. Also, there was a statistical agreement between samples that were macroscopically “insufficient” or “sufficient” with “inadequate” and “dubious” histological results and also between macroscopically “good” and “excellent” samples and histological results that were adequate/diagnostic. And that statistical agreement was of moderate magnitude according to the “Landis and Koch” classification (k = 0.386).

Conclusions

The positive relationship between the on-site macroscopic evaluation of the EBUS sample as “excellent” and the “adequate/diagnostic” histological result is of high clinical importance since it represents a fast, cheap and easy method that provides immediate feedback to the operator influencing his conduct; by obtaining additional passes to achieve an “excellent” will ensure a higher percentage of samples with a diagnosis, accelerating the patients treatment.

Performance of Rapid On-Site Evaluation in Breast Fine-Needle Aspiration Biopsies: Identifying Areas of Diagnostic Challenge

INTRODUCTION

Fine-needle aspiration (FNA) is a well-established method for sampling breast lesions with high accuracy and positive predictive value. Despite its decline in recent years relative to the use of core needle biopsies, there are several advantages to FNA which include cost-effectiveness, low complication rate, and the ability to perform rapid on-site evaluation (ROSE). The aim of this study was to evaluate breast FNAs with ROSE to identify diagnostic challenges during ROSE.

MATERIALS AND METHODS

We identified all breast FNAs with ROSE performed at Massachusetts General Hospital from January 2014 to December 2019. From the electronic medical record, clinical, radiological, and follow-up pathology results were recorded. Comparison between the rapid and final cytological diagnosis was made. All discrepancies were documented with major discrepancy defined as a malignant rapid interpretation not confirmed on final diagnosis or a negative rapid interpretation upgraded to suspicious or positive on final diagnosis.

RESULTS

The study cohort consisted of 483 breast FNAs with ROSE. The rapid and final cytological interpretations showed good correlation, with only 6 (1.2%) major discrepancies. Problematic areas included low-grade, lobular, and fibroepithelial lesions with low cellularity being a contributory factor to misclassification.

CONCLUSIONS

FNA remains a highly accurate method for the evaluation of breast lesions with ROSE.

A modified Papanicolaou Society of Cytopathology system for reporting respiratory cytology specimens: Implications for estimates of malignancy risk and diagnostic accuracy

BACKGROUND

In 2016, the Papanicolaou Society of Cytopathology (PSC) proposed a classification scheme for reporting cytologic specimens obtained from the respiratory system. Diagnostic sensitivity, specificity, and risk of malignancy were reported for endobronchial ultrasound guided fine needle aspiration but data for other sampling techniques has been poorly documented.

METHODS

In 2016, a modified version of the PSC guidelines was adopted at the University of Missouri for classification of sputum, bronchial washing, bronchial brushing, and fine-needle aspiration specimens. Specimens assigned to the negative category included all specimens containing evaluatable inflammatory or epithelial cells including benign appearing respiratory epithelium. Only specimens with marked artifactual distortion or obscuring blood or mucus were placed in the non-diagnostic category.

RESULTS

672 bronchial washing specimens (479 with histology) and 511 bronchial brushings specimens (324 with histology) were reviewed. Washing specimens were classified as non-diagnostic (3%), benign (73%), atypical (10%), suspicious (4%), and malignant (10%). Bronchial brushing specimens were classified non-diagnostic (0.4%) benign (73%), atypical (6%), suspicious (3%), and malignant (17%). Malignancy risks for bronchial washings were insufficient (50%), benign (38%), atypical (62%), suspicious (83%), and malignant (98%). Risks of malignancy for bronchial brushings were insufficient (0%), benign (32%), atypical (79%), suspicious (75%), and malignant (94%).

CONCLUSION

Malignancy risks associated with bronchial washings and bronchial brushings are different than those reported for EBUS FNA. When the benign category includes specimens with "normal" appearing cellular elements, the risk of malignancy is substantial (between 32% and 38%).

Impact of EBUS-TBNA in addition to [18F]FDG-PET/CT imaging on target volume definition for radiochemotherapy in stage III NSCLC

Purpose/introduction

[¹⁸F]FDG-PET/CT is the standard imaging-technique for radiation treatment (RT) planning in locally advanced non-small cell lung cancer (NSCLC). The purpose of this study was to examine the additional value of endobronchial-ultrasound transbronchial needle aspiration (EBUS-TBNA) to standard PET/CT for mediastinal lymph-node (LN) staging and its impact on clinical target volume (CTV).

Materials and methods

All consecutive patients with primary stage III NSCLC who underwent [¹⁸F]FDG-PET/CT and EBUS-TBNA prior to RT were analyzed from 12/2011 to 06/2018. LN-stations were assessed by an expert-radiologist and a nuclear medicine-physician. CTV was evaluated by two independent radiation oncologists. LNs were grouped with increasing distance along the lymphatic chains from primary tumor into echelon-1 (ipsilateral hilum), echelon-2 (LN-station 7 and ipsilateral 4), and echelon-3 (remaining mediastinum and contralateral hilum).

Results

A total of 675 LN-stations of which 291 were positive for tumor-cells, were sampled by EBUS-TBNA in 180 patients. The rate of EBUS-positive LNs was 43% among all sampled LNs. EBUS-positivity in EBUS-probed LNs decreased from 85.8% in echelon-1 LNs to 42.4%/ 9.6% in echelon-2/ -3 LNs, respectively (p < 0.0001, Fisher’s exact test). The false discovery rate of PET in comparison with EBUS results rose from 5.3% in echelon-1 to 32.9%/ 69.1% in echelon-2/ -3 LNs, respectively (p < 0.0001, Fisher’s exact test). Sensitivity and specificity of FDG-PET/CT ranged from 85 to 99% and 67 to 80% for the different echelons. In 22.2% patients, EBUS-TBNA finding triggered changes of the treated CTV, compared with contouring algorithms based on FDG-avidity as the sole criterion for inclusion. CTV was enlarged in 6.7% patients due to EBUS-positivity in PET-negative LN-station and reduced in 15.5% by exclusion of an EBUS-negative but PET-positive LN-station.

Conclusion

The false discovery rate of [¹⁸F]FDG-PET/CT increased markedly with distance from the primary tumor. Inclusion of systematic mediastinal LN mapping by EBUS-TBNA in addition to PET/CT has the potential to increase accuracy of target volume definition, particularly in echelon-3 LNs. EBUS-TBNA is recommended as integral part of staging for radiochemotherapy in stage III NSCLC.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00259-021-05204-7.

Do Not Ignore Tuberculosis of the Parotid Gland When Meeting Obvious Infiltration of Neutrophils in a Suspicious Swelling by FNAC

Parotid gland tuberculosis constantly results in unnecessary medical examinations and surgery because of its similarities in the presentation to neoplasms of the parotid gland. Although parotid gland involvement is extremely rare even in tuberculosis-endemic countries, accurate diagnosis of this clinical entity is of great significance because tuberculous parotitis can be successfully treated medically without surgical therapy. Fine needle aspiration cytology (FNAC) and molecular identification of the parotid swellings are efficient in making a rapid diagnosis. Herein, we report an early misdiagnosis of malignancy from a renal transplantation patient on long-term immunologic inhibitor therapy, who ultimately proved to have tuberculosis of the parotid gland by FNAC and molecular identification. The aim of this study is to describe and analyze the etiologic characteristics, epidemiology, clinical presentations, diagnostic methods, histopathologic findings, and pathogenic mechanisms of these rare infections.

Results from the 2019 American Society of Cytopathology survey on rapid onsite evaluation (ROSE)-part 2: subjective views among the cytopathology community

INTRODUCTION

This study aims to improve understanding of the cytopathology community's perspective regarding the value of rapid onsite evaluation (ROSE) in clinical practice.

MATERIALS AND METHODS

The American Society of Cytopathology membership was surveyed in 2019 to obtain subjective data on the cytopathology community's perceptions regarding ROSE. Comments were categorized by major themes and attitudes and analyzed by respondent's role in laboratory, practice size, and practice setting (Fisher's exact and χ² tests).

RESULTS

A total of 541 responses were received from 255 cytopathologists/pathologists, 261 cytotechnologists, 19 trainees, and 6 others (as previously reported). Reasons for which cytopathology personnel provide this service aligned with their perceptions of why clinicians request ROSE. A minority of respondents, disproportionally from high volume centers, felt ROSE is unnecessary. Overall attitude regarding ROSE was generally positive. There were no significant differences in attitude regarding ROSE according to role in laboratory or practice size, but respondents from academic centers provided a significantly higher percentage of positive comments than those in private or community practice. Although survey respondents generally felt that ROSE is valuable to patient care, they also highlighted several challenges, including staffing, time commitment, and inadequate reimbursement. Implementation of telecytology was felt to potentially alleviate some of these challenges.

CONCLUSIONS

Survey results show that the cytology community views ROSE favorably, practices vary considerably, and there is a perceived need for improved reimbursement. Data from this study may be used to identify areas that warrant additional research to clarify the clinical value of ROSE.

Mediastinal sarcomas: experience using fine needle aspiration cytopathology

Fine needle aspiration (FNA) cytology is a sparsely used diagnostic method in the evaluation of mediastinal sarcomas in most medical centers worldwide with most literature citations regarding this category of malignancies consisting of small series and individual case reports. Most of these published studies highlight vascular sarcomas such as epithelioid hemangioendothelioma, and angiosarcoma, various subtypes of liposarcoma including well-differentiated liposarcoma, myxoid liposarcoma, and pleomorphic liposarcoma, malignant peripheral nerve sheath tumor, and sarcomas of uncertain differentiation, primary synovial sarcoma and the Ewing sarcoma family of tumors. This paucity of cytopathology reports regarding mediastinal sarcomas is in marked contrast to the almost daily application of endobronchial ultrasound (EBUS)-guided FNA biopsy for sampling mediastinal lymph nodes and mediastinal masses for primary and metastatic carcinomas which, of course, are considerably more common that any type of sarcoma in this location. EBUS, endoscopic ultrasound-guided (EUS) needle biopsy, and percutaneous image-guided biopsy using either core needle, fine-needle, or both can serve a potentially useful role for diagnostic sampling of mediastinal sarcomas, be they primary or metastatic. This review catalogues much of the published data regarding FNA cytopathology and its application to mediastinal sarcomas. An attempt is made to primarily highlight case series rather than individual case reports; however, due to the paucity of these, case reports are cited and discussed where appropriate.

Collection and Handling of Thoracic Small Biopsy and Cytology Specimens for Ancillary Studies: Guideline From the College of American Pathologists in Collaboration With the American College of Chest Physicians, Association for Molecular Pathology, American Society of Cytopathology, American Thoracic Society, Pulmonary Pathology Society, Papanicolaou Society of Cytopathology, Society of Interventional Radiology, and Society of Thoracic Radiology

CONTEXT.—

The need for appropriate specimen use for ancillary testing has become more commonplace in the practice of pathology. This, coupled with improvements in technology, often provides less invasive methods of testing, but presents new challenges to appropriate specimen collection and handling of these small specimens, including thoracic small biopsy and cytology samples.

OBJECTIVE.—

To develop a clinical practice guideline including recommendations on how to obtain, handle, and process thoracic small biopsy and cytology tissue specimens for diagnostic testing and ancillary studies.

METHODS.—

The College of American Pathologists convened an expert panel to perform a systematic review of the literature and develop recommendations. Core needle biopsy, touch preparation, fine-needle aspiration, and effusion specimens with thoracic diseases including malignancy, granulomatous process/sarcoidosis, and infection (eg, tuberculosis) were deemed within scope. Ancillary studies included immunohistochemistry and immunocytochemistry, fluorescence in situ hybridization, mutational analysis, flow cytometry, cytogenetics, and microbiologic studies routinely performed in the clinical pathology laboratory. The use of rapid on-site evaluation was also covered.

RESULTS.—

Sixteen guideline statements were developed to assist clinicians and pathologists in collecting and processing thoracic small biopsy and cytology tissue samples.

CONCLUSIONS.—

Based on the systematic review and expert panel consensus, thoracic small specimens can be handled and processed to perform downstream testing (eg, molecular markers, immunohistochemical biomarkers), core needle and fine-needle techniques can provide appropriate cytologic and histologic specimens for ancillary studies, and rapid on-site cytologic evaluation remains helpful in appropriate triage, handling, and processing of specimens.

Translational research: Empowering the role of pathologists and cytopathologists

Research activity is in the core essence of pathology. Advancing our understanding of disease pathogenesis translates into better patient care. Because of their unique position, laboratorians are the best to accurately identify, annotate, and classify research specimens. They also are essential for the accurate interpretation of genomic testing. Currently, cytopathologists are moving to the center of patient care through active communication with clinicians and patients. There are certain research areas in which cytopathologists can be pioneers, such as image analysis, morphology research, and genotype-phenotype association studies integrating morphologic and molecular features. Health service utilization research is another domain in which cytopathologists can excel. Successful research is a journey that necessitates multiple steps. It also involves building expertise in how to overcome obstacles and handle challenges.

Endobronchial ultrasound-guided transbronchial fine needle aspiration: Determinants of adequacy

Background

This study aims to evaluate the factors influencing the adequacy of endobronchial ultrasound-guided transbronchial fine needle aspiration specimens.

Methods

A retrospective analysis of 1,700 endobronchial ultrasound-guided transbronchial fine needle aspiration samples obtained from 822 patients (500 males, 322 females; mean age 56±13 years; range 16 to 83 years) was performed between March 2011 and March 2014 at our center. Variables potentially associated with sampling adequacy, such as all cytological materials and procedure notes (lymph node and/or lesion size, localization, needle pass number, and slide number) were examined.

Results

The overall specimen adequacy was 79.8%. The specimen adequacy was associated with needle pass number (p≤0.001). Adequacy rate was 66.9% for one needle pass and 85.8% for three needle passes. According to the sampling regions, adequacy rates showed a difference [69.2%-85.8%; (p≤0.005)]. In the multivariate logistic regression analysis of subcarinal (7) lymph node station, patient age (odds ratio, 0.983; 95% confidence interval, 0.966-1.000; p=0.049) and number of slides (odds ratio, 1.240; 95% confidence interval, 1.062-1.448; p=0.006) were independent determining factors of specimen adequacy. While independent determinants of specimen adequacy for the right paratracheal (4R) region were lymph node size (odds ratio, 1.486; 95% confidence interval, 0.973-2.268; p=0.067) and number of slides (odds ratio, 1.418; 95% confidence interval, 1.146-1.756; p=0.001), they were lymph node size (odds ratio, 1.594; 95% confidence interval, 0.960-2.645; p=0.071) and number of needle passes (odds ratio, 2.277; 95% confidence interval, 1.360-3.811; p=0.002) for the right interlobar (11R) region. Independent determinant of specimen adequacy for the left paratracheal (4L) lymph node station was the number of needle passes (odds ratio, 1.656; 95% confidence interval, 0.955-2.869; p=0.072).

Conclusion

During endobronchial ultrasound-guided transbronchial fine needle aspirations, particularly when rapid on site evaluation cannot be applied, consideration of factors affecting adequacy according to lymph node localizations may increase the chance for obtaining materials with suitable quality for cytologic evaluation.

Rapid On-Site Evaluation of Endobronchial Ultrasound–Guided Transbronchial Needle Aspirations for the Diagnosis of Lung Cancer: A Perspective From Members of the Pulmonary Pathology Society

Context.—

Endobronchial ultrasound–guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a very useful tool in the field of diagnostic respiratory cytology. Rapid on-site evaluation (ROSE) of EBUS-TBNA not only has the potential to improve diagnostic yield of the procedure but also to triage samples for predictive molecular testing to guide personalized treatments for lung cancer.

Objective.—

To provide an overview of the current status of the literature regarding ROSE of EBUS-TBNA in the diagnosis of lung cancer.

Data Sources.—

An electronic literature search in PubMed and Google databases was performed using the following key words: cytology, lung cancer, on-site evaluation, rapid on-site evaluation, and ROSE EBUS-TBNA. Only articles published in English were included in this review.

Conclusions.—

Rapid on-site evaluation can ensure that the targeted lesion is being sampled and can enable appropriate specimen triage. If available, it should be used with EBUS-TBNA in the diagnosis of lung cancer because it can minimize repeat procedures for additional desired testing (ie, molecular studies). Some studies have shown that ROSE does not adversely affect the number of aspirations, total procedure time of EBUS-TBNA, or the rate of postprocedure complications; it is also helpful in providing a preliminary diagnosis that can reduce the number of additional invasive procedures, such as mediastinoscopy. As EBUS technology continues to evolve, our knowledge of the role of ROSE in EBUS-TBNA for the diagnosis of lung cancer will also continue to grow and evolve.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: A Pilot Study to Evaluate the Utility of the ProCore Biopsy Needle for Lymph Node Sampling

OBJECTIVE

The ProCore ultrasound biopsy needle, used primarily to obtain intra-abdominal tissue core biopsies, has not been widely used for endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). In this pilot study we evaluated the utility of the ProCore needle for sampling mediastinal or hilar lymph nodes during EBUS-TBNA.

DESIGN

Thirty-two patients were identified using both ProCore and conventional fine-needle aspiration (FNA) needles for sampling mediastinal or hilar lymph nodes (the study group). Another 33 patients underwent EBUS-TBNA using an FNA needle only (the control group). Specimen satisfactory rates were compared between the study and control groups. Aspirate smears and cell blocks were evaluated for the cellularity of lesional cells and bronchial contamination in a subset of patients in the study group.

RESULTS

Overall, the ProCore needle did not show additive value to specimen adequacy when comparing the satisfactory rates of the study and control groups (94 vs. 89%). The ProCore needle also did not procure significantly more lesional cells than the FNA needle.

CONCLUSION

Our experience shows that the ProCore needle does not provide additive value when performing an FNA of mediastinal or hilar lymph nodes. The evaluation of more cases with this new technique is necessary to better determine the clinical utility of using ProCore during EBUS-TBNA.

Respiratory Cytology--Current Trends Including Endobronchial Ultrasound-Guided Biopsy and Electromagnetic Navigational Bronchoscopy: Analysis of Data From a 2013 Supplemental Survey of Participants in the College of American Pathologists Interlaboratory Comparison Program in Nongynecologic Cytology

CONTEXT

Nongynecologic cytology (NGC) practices are expanding in relationship to historical gynecologic cytology screening programs. Bronchopulmonary cytology is experiencing an evolution regarding new procedural types. The College of American Pathologists (CAP) tracks practice patterns in NGC by developing questionnaires, surveying participants, and analyzing respondent data.

OBJECTIVE

To analyze responses to a 2013 CAP supplemental survey from the Interlaboratoy Comparison Program on bronchopulmonary NGC.

DESIGN

The "NGC 2013 Supplemental Questionnaire: Demographics in Performance and Reporting of Respiratory Cytology" was mailed to 2074 laboratories.

RESULTS

The survey response rate was 42% (880 of 2074) with 90% of respondents (788 of 880) indicating that their laboratories evaluated cytology bronchopulmonary specimens. More than 95% of respondents indicated interpreting bronchial washings (765 of 787) and bronchial brushings (757 of 787). A minority of laboratories (43%, 340 of 787) dealt with endobronchial ultrasound-guided samples, and an even smaller fraction of laboratories (14%, 110 of 787) saw cases from electromagnetic navigational bronchoscopy. Intraprocedural adequacy assessments by pathologists (and less often by cytotechnologists or pathologists-in-training) were routinely performed in percutaneous transthoracic aspiration cases (74%, 413 of 560) with less involvement for other case types. Most laboratories reported that newly diagnosed primary pulmonary adenocarcinomas were triaged for molecular testing of epidermal growth factor receptor and anaplastic lymphoma kinase.

CONCLUSIONS

The parameters examined in this 2013 survey provide a snapshot of current pulmonary cytopathology practice and may be used as benchmarks in the future.

A single EBUS-TBNA procedure can support a large panel of immunohistochemical stains, specific diagnostic subtyping, and multiple gene analyses in the majority of non-small cell lung cancer cases

Targeted therapies for pulmonary adenocarcinoma (ACA) necessitate specific subtyping and molecular testing of non-small cell lung carcinomas (NSCLC). However, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has decreased the tissue available for these assessments. While EBUS-TBNA specimens have previously been reported to successfully subtype NSCLC, allow immunohistochemistry (IHC), and support molecular diagnostics, no studies have documented the extent to which all objectives are possible in a single sample. Of 107 consecutive EBUS-TBNA specimens that were eligible for molecular testing, 98.8% had enough tissue for IHC, 80.2% received a definitive subtype, and 71.0% had both sufficient tissue to attempt molecular testing and technical success on multigene next-generation sequencing and ALK fluorescence in situ hybridization assays. Both subtyping and molecular diagnostics were possible in 57.9% of patients. The mean number of immunostains performed did not differ between patients with or without successful molecular testing (4.4 versus 4.6, P = .88). Only 40% of patients with insufficient tissue underwent repeat sampling. These findings indicate that a majority of EBUS-TBNA specimens provide sufficient tissue for subtyping pulmonary NSCLC, performing IHC, and completing multiple gene analyses. Although priorities must be assessed for each case individually, performance of IHC does not detract from completion of molecular diagnostics in general. Because most patients never undergo repeat sampling, the tissue yield of EBUS-TBNA should be improved to maximize evaluation for targeted therapies.

Recent advances in the pathology and molecular genetics of lung cancer: A practical review for cytopathologists

Lung cancer is one of the most common causes of cancer-related death worldwide. Better understanding of the molecular genetic characteristics of non-small cell lung carcinoma (NSCLC), particularly adenocarcinoma, has opened the opportunity for targeted therapies. With the different molecular abnormalities and the different responses to new targeted therapies based on the histological subtype of NSCLC, there came a need to further classify NSCLC into squamous cell carcinoma and adenocarcinoma, and to perform the appropriate molecular testing in these different subtypes to guide management decisions. Given that approximately 70% of lung cancer patients have only small biopsies or cytology specimens available, incorporating the testing of these specimens into the cytopathology laboratory has been crucial. Herein, we review current concepts and recommendations on NSCLC subtyping and molecular testing that are relevant for the cytopathology community.

Endobronchial ultrasonography-guided transbronchial needle aspiration, an effective modality for sampling targeted thoracic lesions in adult lung transplant recipients

INTRODUCTION

Lung transplantation (LTx) is performed for end-stage lung diseases that would be otherwise fatal. Pulmonary allograft recipients are a unique patient population as they are at high risk for malignancy and infectious complications due to the need for immunosuppression. Endobronchial ultrasonography (EBUS)-guided fine-needle aspiration (FNA) is a minimally invasive technique for evaluating abnormalities of the mediastinum/lungs. To our knowledge, this report is the first in the literature addressing targeted EBUS-FNA biopsies in patients who have undergone LTx.

MATERIAL AND METHODS

During 5 years from May 1, 2009 to May 1, 2014, 582 patients underwent LTx at the Cleveland Clinic. A review of records indicated that 14 of these patients later underwent EBUS-FNA. Demographic and diagnostic parameters were recorded.

RESULTS

A total of 14 patients (mean age 64 years) underwent EBUS-FNA after LTx. The mean interval between LTx and EBUS-FNA was 15 months. EBUS-FNA yielded cytologic material diagnostic of malignancy in 10 patients (71%) with one-half of those cases being squamous carcinomas.

CONCLUSIONS

EBUS-FNA is a useful diagnostic modality in lung allograft recipients and is of value in confirming and staging thoracic malignancies in this population. Carcinoma subtyping is feasible by EBUS-FNA, and performance of ancillary studies to confirm clonality in post-transplant lymphoproliferative disorders is possible.

Malignancy risk associated with the EBUS-FNA diagnostic categories nondiagnostic, benign, atypical, suspicious for malignancy, and malignant for mediastinal lymph node aspirate specimens

INTRODUCTION

Endobronchial ultrasonography-guided transbronchial fine-needle aspiration (EBUS-TBFNA) is used for preoperative staging of primary lung carcinomas. Published sensitivity and specificity are up to 86% and 100%, respectively. Diagnostic categories used by many cytopathologists are nondiagnostic, benign, atypical, suspicious, and malignant. Little information exists about the risk of malignancy associated with each of these categories.

MATERIALS AND METHODS

Records of the Department of Pathology at the University of Utah were searched for all EBUS-TBFNAs of mediastinal and pulmonary hilar lymph nodes. Only cases with surgical follow-up were included in this study. For each diagnostic category (nondiagnostic, benign, atypical, suspicious, and malignant), the percentage of cases proven to be malignant was calculated following correlation of cytologic and surgical diagnoses. Positive and negative predictive values were calculated. For calculation of accuracy statistics, atypical cases were considered benign and suspicious cases were classified as malignant.

RESULTS

For this study, 136 EBUS-TBFNAs of lymph nodes were obtained with adequate surgical follow-up. Risk of malignancy for nondiagnostic specimens was 42%, benign specimens 32%, atypical specimens 40%, suspicious specimens 83%, and malignant specimens 84%. Positive predictive value was 84%, and negative predictive value was 68%.

CONCLUSIONS

The categories stratified malignancy risk ranging from a low of 32% for benign to 84% for malignant. The categories suspicious and malignant had similar malignancy risks. Atypical aspirates had a higher malignancy risk than benign aspirates did. Nondiagnostic aspirates had a malignancy risk similar to that of atypical aspirates. This scoring system may aid in treatment planning and patient counselling.

Utility and diagnostic accuracy of endobronchial ultrasound-guided transbronchial fine-needle aspiration cytology of mediastinal lesions: Saudi Arabian experience

Objective:

The objective of this study is to evaluate the cytological accuracy of endobronchial ultrasound-guided transbronchial fine-needle aspiration (EBUS-TFNA) of the mediastinal mass/nodular lesions.

Study Design:

Over 3½ years from inception at King Khalid University Hospital, a retrospective analysis of the cytological diagnoses of all the EBUS-TFNA procedures performed in 80 patients who had mediastinal mass/nodular enlargement. Cytology results were reviewed and correlated with the histologic follow-up.

Results:

Of the 80 patients who underwent EBUS-TFNA, 15 cases (18.75%) were positive for malignancy, 48 cases (60%) negative for malignancy and 17 cases (21.25%) unsatisfactory. Of the 48 cases, which were negative for malignancy, 24 (50%) cases were of granulomatous inflammation. The overall diagnostic yield of our EBUS-TFNA specimen was 78.75%. Forty-seven cases (58.75%) of 80 cases had histological follow-up biopsies. Among them, 32 cases (68%) had the same cytological and histological diagnosis and 15 cases (31.09%) had discordance between the cytology and the follow-up histological diagnosis. The sensitivity, specificity, and positive and negative predictive values for diagnosing granulomas by EBUS-TFNA are 77%, 82%, 83%, and 75% and for diagnosing malignancy are 71%, 100%, 100%, and 82%, respectively.

Conclusion:

Preliminary results show that cytological samples obtained through EBUS-TFNA are accurate and specific in making a diagnosis of the mediastinal mass/nodular lesions. Its optimum use depends on the effective collaboration between the cytotechnologist, pathologist, and the bronchoscopist.

Outcome of patients with negative and unsatisfactory cytologic specimens obtained by endobronchial ultrasound-guided transbronchial fine-needle aspiration of mediastinal lymph nodes

BACKGROUND

Endobronchial ultrasound-guided transbronchial fine-needle aspiration (EBUS-FNA) has gained acceptance as the diagnostic procedure of choice with which to sample hilar and mediastinal lymph nodes (LNs) for diagnosing and staging patients with lung cancer. Studies have shown that EBUS has a high positive predictive value; however, its negative predictive value (NPV) varies significantly. The aim of the current study was to evaluate the clinical outcome surrounding negative and nondiagnostic EBUS-FNA of mediastinal LNs.

METHODS

A retrospective chart review of cases of EBUS-FNA performed between 2008 and the middle of 2011 was conducted. Mediastinal LNs with cytologic diagnoses of negative for malignant cells and unsatisfactory were selected for the study. Each LN was followed for up to 1 year with imaging or biopsy/surgical resection. A true-negative result was defined as a LN that did not enlarge on repeat imaging or was negative for malignancy on repeat biopsy or surgery during the follow-up period.

RESULTS

Among 1418 LNs sampled, 479 from 228 patients met the search criteria, including 394 LN (82.3%) with the cytologic diagnosis of negative for malignant cells and 85 (17.8%) with a diagnosis of unsatisfactory. A total of 104 patients (45.6%) were followed with imaging, and 124 patients (54.3%) underwent repeat biopsy/surgery. A total of 445 LNs met the definition of a true-negative finding, resulting in an overall NPV of 92.9% (95% confidence interval [95% CI], 90.6%-95.2%). The NPVs of a negative and unsatisfactory diagnosis were 93.9% (95% CI, 91.6%-96.3%) and 88.2% (95% CI, 81.4%-95.1%), respectively.

CONCLUSIONS

The vast majority of LNs with a cytologic diagnosis of negative and unsatisfactory were likely to be true-negative findings. In these patients, a more conservative approach to follow-up may be appropriate.