[Bronchoalveolar lavage]

Bronchoscopic performance of bronchoalveolar lavage in germany - a call for standardization

Background:

Bronchoalveolar lavage (BAL) is a widely used clinical tool in diagnosing interstitial lung diseases. Although there are recommendations and guidelines, the procedure is not completely standardized. Varying approaches likely influence the conclusiveness of BAL data and may be one reason for the divergent judgement of their value between different centers.

Objectives:

To evaluate how BAL is performed in Germany using an electronically based survey.

Methods:

We conducted a cross-sectional online survey among all members of the German Respiratory Society.

Results:

608 members responded to the survey and of these 500 perform lavages. Most bronchoscopists (344/500) do not use a tube and have no anesthesiologist present during the procedure (405/500). Propofol is used by 76.8% and midazolam by 67.9% (n = 405), often in combination. A major difference was noted regarding the total volume of instillation. Many respondents use a predefined fixed amount of instilled volume (202/500), whereas an almost equal number use variable volumes based on the recovery (196/500). The minimum recovery volume predefined by 217/499 ranged from 3-150 ml (median 30 ml; mean 42.2 ± 55.1 ml). Most respondents did not transport their samples in special medium (61.5%) or on ice (72.8%). The average time between recovery and arrival at the lab was 115.6±267.0 min (n = 323).

Conclusion:

This study shows the broad spectrum of variations in the performance of BAL in Germany, which could have a negative effect on the method’s clinical value. There is a need for training and standardization of BAL performance.

[Bronchoalveolar lavage in hairy cell leukemia with pulmonary infiltration]

We report a 78-year-old male patient suffering from hairy cell leukemia, presenting clinically mainly with dyspnea. Radiology exhibited bilateral ground-glass shadows. In order to prevent pneumonia as a possible side effect due to conventional chemotherapy, it was decided to first treat the patient with rituximab; however, dyspnea persisted. Therefore, bronchoscopy was performed and specimens were sampled for both histological examination and bronchoalveolar lavage (BAL) analysis. BAL showed lymphocytosis (28.7%), and by means of immunocytochemistry a few CD79a+ B‑lymphocytes as well as lymphoid cells positive for the hairy cell marker DBA44 were observed. In addition, molecular study revealed the BRAF V600E mutation. Thus, the findings of BAL were interpreted as lung infiltration by hairy cell leukemia. This result was confirmed by histology. Following a therapy switch to cladribine, a significant improvement was reached. Pulmonary infiltrates by hairy cell leukemia were rarely described. This case represents the first report of hairy cell leukemia diagnosed by means of BAL. It may be difficult to clearly separate between lymphoma infiltration of the lung and medicamentous pneumonitis, but this differential diagnosis can be supported by morphological methods.

Diagnostic Value of Bronchoalveolar Lavage for Diagnosis of Suspected Peripheral Lung Cancer

BACKGROUND

There is a paucity of data concerning the benefit of bronchoalveolar lavage (BAL) for the diagnosis of suspected peripheral lung cancer (PLC). The aim of this study was to investigate the diagnostic value of BAL for the diagnosis of suspected PLC.

PATIENTS AND METHODS

All flexible bronchoscopies that included BAL among other modalities (brush, forceps, washing) for the diagnosis of a suspected PLC performed between 2009 and 2013 were analyzed in this retrospective study.

RESULTS

A total of 260 patients were included. Malignancy was present in 61%. BAL's sensitivity for the diagnosis of malignancy was 29%, and overall diagnostic yield of BAL was 46%. However, only 1% of cancer diagnoses would have been missed in the absence of BAL. In the multivariable analysis, the size of lesion (odds ratio [OR], 1.17; 95% confidence interval [CI], 1.02-1.33; P = .023), the presence of bronchus sign (OR, 4.73; 95% CI, 1.06-21.08; P = .042), and the presence of mediastinal/hilar lymphadenopathy (OR, 3.37; 95% CI, 1.53-7.41; P = .002) were associated with improved BAL true-positive ratio relating to diagnosis of malignancy. However, the effect of lesion size on sensitivity was small (area under the curve, 0.31; 95% CI, 0.23-0.40; P < .001). Ground-glass lesions were not associated with improved BAL diagnostic value. The number needed to test for BAL for the diagnosis of malignancy or pulmonary infection was 37.

CONCLUSION

Conventional BAL has a low diagnostic value for the diagnosis of suspected PLC, and the low number needed to test does not qualify BAL as a recommended routine investigation for the diagnosis of suspected PLC for either solid or ground-glass lesions.

Preanalytics in lung cancer

Preanalytic sampling techniques and preparation of tissue specimens strongly influence analytical results in lung tissue diagnostics both on the morphological but also on the molecular level. However, in contrast to analytics where tremendous achievements in the last decade have led to a whole new portfolio of test methods, developments in preanalytics have been minimal. This is specifically unfortunate in lung cancer, where usually only small amounts of tissue are at hand and optimization in all processing steps is mandatory in order to increase the diagnostic yield. In the following, we provide a comprehensive overview on some aspects of preanalytics in lung cancer from the method of sampling over tissue processing to its impact on analytical test results. We specifically discuss the role of preanalytics in novel technologies like next-generation sequencing and in the state-of the-art cytology preparations. In addition, we point out specific problems in preanalytics which hamper further developments in the field of lung tissue diagnostics.

Respiratory Tract and Mediastinum

Normal cytology, abnormal and atypical cells, non-cellular components, and infectious cell changes are largely described together with benign, malignant, and neuroendocrine lesions regarding exfoliative and aspiration cytology of the lung. A separate section broadly addresses diagnostic findings and differential diagnoses in bronchoalveolar washings.

The section ‘Fine needle aspiration biopsy of mediastinal disorders’ covers in particular biopsy techniques, accuracy of liquid-based cytology, and the complex lesions of the thymus gland. Cytodiagnostic algorithms of the major benign and malignant pulmonary and mediastinal lesions and their respective differential diagnoses are additionally presented in synoptic setups.

Toxic alveolitis after inhalation of a water repellent

Inhalation of fluorocarbon polymers can cause pulmonary toxicity. Although multiple cases of lung injury have been reported, cellular characterization of the associated alveolitis occurring acutely after inhalation is limited. We report the case of a previously healthy woman who presented at our Emergency Department with an acute pneumonitis following inhalation of a fluorocarbon polymer-based rain-proofing spray. Bronchoalveolar lavage (BAL) performed shortly after the presentation showed an elevated total cell count, with a high proportion of neutrophils (58%) and eosinophils (9%). In addition, a lipid stain (Oil-Red-O-stain) showed a high level of lipid laden macrophages, a marker that could reflect a direct toxic effect of the spray on alveolar cells. The patient made a full recovery after four days of in-hospital observation with supportive care.