Are EUS-FNA and EBUS-TBNA specimens reliable for subtyping non-small cell lung cancer?

The Value and Limitations of Cell Blocks in Endobronchial Ultrasound-Guided Fine-Needle Aspiration Cytology: Experience of a Tertiary Care Center in North India

Background:

Endobronchial ultrasound (EBUS)-guided fine-needle aspiration cytology (FNAC) is recommended for diagnosing bronchial neoplasms and evaluating mediastinal lymph nodes. However, it may not be possible to subtype or definitely categorize many bronchial neoplasms on FNAC smears alone. Obtaining adequate diagnostic material is often a problem. In such cases, cell blocks made from FNAC material may serve as a useful adjunct. Aim: To study the value and limitations of cell blocks in adding diagnostic information to EBUS guided FNAC smears.

Material and Methods:

One hundred and eighty-five cases of EBUS guided FNAC having concomitant cell blocks were reviewed. The cases were evaluated for the extent of adequacy, of definite benign/malignant categorization and of definite subtyping in malignant tumors in these cases. The proportion of cases in which cell blocks added information to FNAC smears alone for the above parameters were calculated.

Results:

Cell blocks provided additional information in 31 out of 185 cases. Cell blocks were necessary for subtyping 24/59 malignant tumors, definite categorization into benign and malignant in 10/140 adequate samples, and increasing adequacy in 6/185 total samples. A total of 45 samples were inadequate in spite of adding information from cell blocks to smears.

Conclusion:

Cell blocks added clinically significant information to EBUS guided FNAC and should be used routinely. To make it more useful, alternative methods of cell block preparation (including proprietary methods) may be evaluated.

Diagnostic Imaging and Newer Modalities for Thoracic Diseases: PET/Computed Tomographic Imaging and Endobronchial Ultrasound for Staging and Its Implication for Lung Cancer

Modalities to detect and characterize lung cancer are generally divided into those that are invasive [endobronchial ultrasound (EBUS), esophageal ultrasound (EUS), and electromagnetic navigational bronchoscopy (ENMB)] versus noninvasive [chest radiography (CXR), computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI)]. This chapter describes these modalities, the literature supporting their use, and delineates what tests to use to best evaluate the patient with lung cancer.

Endobronchial ultrasound guided transbronchial needle aspiration combining with immunohistochemistry and genotype in lung cancer: A single-center, 55 cases retrospective study

OBJECTIVE

The purpose of this study was to evaluate the utility of EBUS-TNA for mediastinal mass or suspected lung cancer patients with mediastinal or hilar lymph node enlarged. Further to investigate the clinical value of EBUS-TBNA combining with immunohistochemistry and genotype in lung cancer.

METHODS

A total of 55 patients with mediastinal, and/or hilar lymphadenopathy, and/or mediastinal mass previously detected by CT or PET/CT scan and who underwent EBUS-TBNA. An additional immunohistological analysis was performed for establishing a reliable diagnosis and sub classification when necessary. Some samples were tested for the EGFR and/or ALK mutations to provide suitable mutational genotyping for adenocarcinoma by using the PCR assays.

RESULTS

Of the 55 patients, the sensitivity and diagnostic accuracy of EBUS-TBNA in the diagnosis of lung cancer were 92.5% (37/40) and 94.5% (52/55), respectively. 37 samples were further confirmed and obtained particular type by Immunohistochemistry. 6 cases of EBUS-TBNA samples from patients with lung adenocarcinoma referred for EGFR testing were analyzed, 4 patients were found to have EGFR gene mutations. The procedure was uneventful without any complications.

CONCLUSION

EBUS-TBNA is a safe and efficient method with high sensitivity and specificity in the diagnosis of lung cancer. Uniquely combining with Immunohistochemistry and molecular testing has significant clinical value in subtype diagnosis and guiding the treatment strategy in lung cancer.

Diagnostic Imaging and Newer Modalities for Thoracic Diseases: PET/Computed Tomographic Imaging and Endobronchial Ultrasound for Staging and Its Implication for Lung Cancer

Modalities to detect and characterize lung cancer are generally divided into those that are invasive [endobronchial ultrasound (EBUS), esophageal ultrasound (EUS), and electromagnetic navigational bronchoscopy (ENMB)] versus noninvasive [chest radiography (CXR), computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI)]. This chapter describes these modalities, the literature supporting their use, and delineates what tests to use to best evaluate the patient with lung cancer.

Accuracy and consequences of same-day, invasive lung cancer workup - a retrospective study in patients treated with surgical resection

BACKGROUND

Though widely used, little is known about accuracy and efficacy of same-day, invasive workup of suspected lung cancer.

OBJECTIVE

To evaluate the accuracy and efficacy of same-day, invasive lung cancer workup (diagnosis and mediastinal staging), and to identify differences between patients without (Group A) or with (Group B) need for resampling.

METHODS

A retrospective study was performed on all consecutive patients referred for surgical treatment for localised lung cancer after invasive diagnostic and staging workup at our unit. Data were extracted from electronic medical files. Surgical specimens served as gold standard for correct diagnosis and stage.

RESULTS

A total of 129 patients (peripheral lesion: 84%; mediastinal staging: 97%) were included. After same-day, invasive workup, 71% had no need for further invasive workup (Group A), while 29% had (Group B). Group A differed significantly from Group B in fewer invasive tests, fewer days from referral to surgery, and lower pneumothorax incidence, while no differences were observed in diagnostic accuracy, cancer subtype, tumour size, tumour stage, peripheral lesion, nodal involvement, gender, or presence of chronic obstructive pulmonary disease. Tumour located in right upper lobe was associated with need for resampling.

DISCUSSION

Our retrospective study suggests that same-day, invasive workup for lung cancer is safe, accurate, and efficacious in reducing time to therapy, even in patients with small lesions and low tumour burden.

Ultrasound techniques in the evaluation of the mediastinum, part I: endoscopic ultrasound (EUS), endobronchial ultrasound (EBUS) and transcutaneous mediastinal ultrasound (TMUS), introduction into ultrasound techniques

Ultrasound imaging has gained importance in pulmonary medicine over the last decades including conventional transcutaneous ultrasound (TUS), endoscopic ultrasound (EUS), and endobronchial ultrasound (EBUS). Mediastinal lymph node staging affects the management of patients with both operable and inoperable lung cancer (e.g., surgery vs. combined chemoradiation therapy). Tissue sampling is often indicated for accurate nodal staging. Recent international lung cancer staging guidelines clearly state that endosonography (EUS and EBUS) should be the initial tissue sampling test over surgical staging. Mediastinal nodes can be sampled from the airways [EBUS combined with transbronchial needle aspiration (EBUS-TBNA)] or the esophagus [EUS fine needle aspiration (EUS-FNA)]. EBUS and EUS have a complementary diagnostic yield and in combination virtually all mediastinal lymph nodes can be biopsied. Additionally endosonography has an excellent yield in assessing granulomas in patients suspected of sarcoidosis. The aim of this review, in two integrative parts, is to discuss the current role and future perspectives of all ultrasound techniques available for the evaluation of mediastinal lymphadenopathy and mediastinal staging of lung cancer. A specific emphasis will be on learning mediastinal endosonography. Part I is dealing with an introduction into ultrasound techniques, mediastinal lymph node anatomy and diagnostic reach of ultrasound techniques and part II with the clinical work up of neoplastic and inflammatory mediastinal lymphadenopathy using ultrasound techniques and how to learn mediastinal endosonography.

Guideline for the acquisition and preparation of conventional and endobronchial ultrasound-guided transbronchial needle aspiration specimens for the diagnosis and molecular testing of patients with known or suspected lung cancer

RATIONALE

Conventional transbronchial needle aspiration (TBNA) and endobronchial ultrasound (EBUS)-TBNA are widely accepted tools for the diagnosis and staging of lung cancer and the initial procedure of choice for staging. Obtaining adequate specimens is key to provide a specific histologic and molecular diagnosis of lung cancer.

OBJECTIVES

To develop practice guidelines on the acquisition and preparation of conventional TBNA and EBUS-TBNA specimens for the diagnosis and molecular testing of (suspected) lung cancer. We hope to improve the global unification of procedure standards, maximize the yield and identify areas for research.

METHODS

Systematic electronic database searches were conducted to identify relevant studies for inclusion in the guideline [PubMed and the Cochrane Library (including the Cochrane Database of Systematic Reviews)].

MAIN RESULTS

The number of needle aspirations with both conventional TBNA and EBUS-TBNA was found to impact the diagnostic yield, with at least 3 passes needed for optimal performance. Neither needle gauge nor the use of miniforceps, the use of suction or the type of sedation/anesthesia has been found to improve the diagnostic yield for lung cancer. The use of rapid on-site cytology examination does not increase the diagnostic yield. Molecular analysis (i.e. EGFR, KRAS and ALK) can be routinely performed on the majority of cytological samples obtained by EBUS-TBNA and conventional TBNA. There does not appear to be a superior method for specimen preparation (i.e. slide staining, cell blocks or core tissue). It is likely that optimal specimen preparation may vary between institutions depending on the expertise of pathology colleagues.

Diagnostic bronchoscopy--current and future perspectives

Lung cancer is the leading cause of cancer-related mortality worldwide. Standard bronchoscopy has limited ability to accurately localise and biopsy pulmonary lesions that cannot be directly visualised. The field of advanced diagnostic bronchoscopy is rapidly evolving due to advances in electronics and miniaturisation. Bronchoscopes with smaller outer working diameters, coupled with miniature radial and convex ultrasound probes, allow accurate central and peripheral pulmonary lesion localisation and biopsy while at the same time avoiding vascular structures. Increases in computational processing power allow three-dimensional reconstruction of computed tomographic raw data to enable virtual bronchoscopy (VB), providing the bronchoscopist with a preview of the bronchoscopy prior to the procedure. Navigational bronchoscopy enables targeting of peripheral pulmonary lesions (PPLs) via a "roadmap", similar to in-car global positioning systems. Analysis of lesions on a cellular level is now possible with techniques such as optical coherence tomography (OCT) and confocal microscopy (CM). All these tools will hopefully allow earlier and safer lung cancer diagnosis and in turn better patient outcomes. This article describes these new bronchoscopic techniques and reviews the relevant literature.

Endoscopic ultrasound-guided sampling in gastroenterology: European society of gastrointestinal endoscopy technical guidelines

At present, the European Society of Gastrointestinal Endoscopy (ESGE) guidelines on endoscopic ultrasound-guided sampling are almost complete and express state of the art developments. However, future developments are anticipated. This editorial focuses on a few recently published papers with some additional information and on two important additional techniques, elastography and contrast enhanced ultrasound (CEUS), which are mentioned, but not explained in detail in the current ESGE guidelines. Elastography and CEUS might be of importance in the near future to improve the biopsy techniques.

The contribution of cell blocks in the diagnosis of mediastinal masses and hilar adenopathy samples from echobronchoscopy

BACKGROUND

Cell block material from puncture can be obtained with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in many cases. The aim of this study was to analyse the value of additional information from cell blocks obtained with EBUS-TBNA samples from mediastinal and hilar lymph nodes and masses.

METHODS

Review of pathology reports with a specific diagnosis obtained from EBUS-TBNA samples of mediastinal or hilar lesions, prospectively obtained over a two-year period. The generation of cell blocks from cytology needle samples, the contribution to morphological diagnosis, and the possible use of samples for immunohistochemistry were analysed.

RESULTS

One hundred and twenty-nine samples corresponding to 110 patients were reviewed. The diagnosis was lung cancer in 81% of cases, extrapulmonary carcinoma in 10%, sarcoidosis in 4%, lymphoma in 2.7%, and tuberculosis in 0.9%. Cell blocks could be obtained in 72% of cases. Immunohistochemistry studies on the cell blocks were significantly easier to perform than on conventional smears (52.6% vs. 14%, P<.0001). In 4cases, the cell block provided an exclusive morphological diagnosis (3sarcoidosis and one metastasis from prostatic carcinoma) and in 3carcinomas, subtype and origin could be identified. Exclusive diagnoses from the cell block were significantly more frequent in benign disease than in malignant disease (25% vs 0.9%, P=.002).

CONCLUSIONS

Cell blocks were obtained from 72% of EBUS-TBNA diagnostic procedures. The main contributions of cell blocks to pathology examinations were the possibility of carrying out immunohistochemical staining for the better classification of neoplasms, especially extrapulmonary metastatic tumours, and the improved diagnosis of benign lesions.

Endoscopic ultrasound-guided tissue acquisition

Endoscopic ultrasound (EUS) is an indispensable tool for tissue acquisition in patients with gastrointestinal tumors. While fine-needle aspiration (FNA) has been routinely carried out for establishing tissue diagnosis, the emerging concept of tailoring chemotherapeutic agents based on molecular markers has increased the demand for core tissue procurement by means of EUS-guided fine-needle biopsy (EUS-FNB). In addition, FNB may offset the limitations of FNA wherein the diagnostic sensitivity is incumbent on the availability of an onsite cytopathologist. Given the increasing number of procedures being done, developing a unit-specific algorithmic approach for needle selection is important to improve the procedural efficiency and utilization of resources. Finally, the best outcomes can be attained only by practicing evidence-based techniques, procuring adequate quantity of sample for ancillary studies and processing the specimens appropriately.

Diagnostic yield and safety of endoscopic ultrasound guided fine needle aspiration of central mediastinal lung masses

Background and Aims. EUS-FNA is an accurate and safe technique to biopsy mediastinal lymph nodes. However, there are few data pertaining to the role of EUS-FNA to biopsy central lung masses. The aim of the study was to assess the diagnostic yield and safety of EUS-FNA of indeterminate central mediastinal lung masses. Methods.

DESIGN

Retrospective review of a prospectively maintained database; noncomparative.

SETTING

Tertiary referral center. From 10/2004 to 12/2010, all patients with a lung mass located within proximity to the esophagus were referred for EUS-FNA.

MAIN OUTCOME MEASUREMENT

EUS-FNA diagnostic accuracy and safety. Results. 73 consecutive patients were included. EUS allowed detection in 62 (85%) patients with lack of visualization prohibiting FNA in 11 patients. Among sampled lesions, one patient (1/62 = 1.6%) had a benign lung mass (hamartoma), while the remaining 61 patients (61/62 = 98.4%) had a malignant mass (primary lung cancer: 55/61 = 90%; lung metastasis: 6/61 = 10%). The sensitivity, specificity, and accuracy of EUS-FNA were 96.7%, 100%, and 96.7%, respectively. The sensitivity was 80.8% when considering nonvisualized masses. One patient developed a pneumothorax (1/62 = 1.6%). Conclusions. EUS-FNA appears to be an accurate and safe technique for tissue diagnosis of central mediastinal lung masses.

Subtyping of nonsmall cell lung cancer on cytology specimens: reproducibility of cytopathologic diagnoses on sparse material

Cytologic examination of fine-needle aspiration (material is increasingly used in diagnosing lung cancer. High interobserver agreement in distinguishing small-cell lung cancer from nonsmall-cell lung cancer (NSCLC) on cytologic material has been demonstrated. Because of new treatment-modalities, subclassification of NSCLC into squamous cell carcinoma (SQC) and non-SQC has clinical impact. Subclassification based on morphology alone may be difficult, but applying immunohistochemistry (IHC) to clot-material has proved helpful. When insufficient material is available to make a clot from the aspirate, cytoscrape (CS) can convert cytologic material into tissue fragments useful for IHC. The purpose of this study was to test the reproducibility of pulmonary malignant diagnoses, in particular distinction between subgroups of NSCLC, based on smeared material and IHC on CS. A consecutive series of May-Grunwald-Giemsa (MGG) stained smears and CS with IHC on material from 79 patients suspected of having lung cancer was included. The material was circulated twice to four pathologists. The diagnoses were categorized in five groups: SQC, adenocarcinoma of the lung, non-SQC, benign lesion and other forms of malignancy, including metastases. Reproducibility was analyzed using Kappa statistics. Interobserver reproducibility of the diagnoses in round 1 was good to very good (kappa 0.57-0.71) and very good in round 2 (0.63-0.80). Reproducibility of subclassification of NSCLC based on MGG stained smear and IHC on CS, was very good among experienced pathologists. With only sparse material available, CS should be used to achieve reproducible diagnoses, including subtyping of NSCLC.