The implementation of liquid-based cytology for lung and pleural-based diseases

The cytologic diagnosis of mesothelioma: are we there yet?

INTRODUCTION

Mesothelioma is a rare but highly aggressive malignancy with poor prognosis that frequently present with recurrent effusions. Establishing the diagnosis by cytology can lead to early diagnosis and treatment and consequently improve prognosis.

MATERIALS AND METHODS

This review examines the cytological diagnosis of mesothelioma in the context of its historical and morphologic evolution and provides an update of the current reporting systems. Clues to identify the mesothelial and malignant nature of the sample are detailed as well as the supporting ancillary tests.

RESULTS

Cytologically, the samples are overwhelmingly cellular and malignancy is recognized by both architectural and cytological atypia. Numerous variably sized clusters and enlarged cells are easily identified, some with papillary architecture and collagen cores. Recognizing the mesothelial nature of the cells and supportive immunostains are essential to rule out the differential diagnosis of metastatic carcinomas and reactive mesothelium. Current ancillary tests such as homozygous deletion of CDKN2A, loss of BRCA1-associated protein, and methylthioadenosine phosphorylase expression can provide further support of malignancy.

CONCLUSIONS

At this time with the aid of current ancillary tests and in the hands of cytopathologists with adequate experience with the interpretation of effusions, the diagnosis of mesothelioma can be established with accuracy in most cases.

Improving Malignancy Detection Rates in Body Fluids Submitted to the Hematology Laboratory for Nucleated Cell Count and Differential: A Quality Improvement Study

CONTEXT.—

Body fluid specimens are regularly submitted to the hematology laboratory for cell count and differential. Unless there is high clinical suspicion for malignancy, most cases lack concurrent cytology review and may not benefit from more focused examination for malignancy.

OBJECTIVE.—

To compare rates of malignancy detection before and after fluid-focused training for hematology technologists as part of a quality improvement initiative.

DESIGN.—

During an 8-week pretraining period, body fluids submitted to the cytology laboratory were correlated with concurrent hematology specimens. After slide review and training sessions for the hematology technologists, the same data were collected for a 4-week period. Discrepant cases were reviewed by hematology laboratory supervisors and pathologists.

RESULTS.—

We collected 465 pretraining and 249 posttraining body fluids with concurrent cytology and hematology evaluation. In the pretraining cohort, 48 cases (10.3%) were diagnosed as malignant by cytology; of those, 33 were detected by hematology. In the posttraining cohort, 30 cases (12.0%) were diagnosed as malignant by cytology of which 27 were detected by hematology. Of the 18 discrepant cases (all carcinomas), hematology slide review showed definite features of malignancy in 15 and no tumor cells in 3. The malignancy detection rate by the hematology laboratory significantly improved after training (68.8% versus 90.0%, P = .01).

CONCLUSIONS.—

We demonstrate the comparatively lower malignancy detection rate for body fluid specimens processed in our hematology laboratory, particularly for carcinomas. Hematology technologist education/training improved the malignancy detection rate, an important quality improvement given the large proportion of body fluids undergoing hematology evaluation without concurrent cytology reviews.

[Cytology of primary lung cancer]

BACKGROUND

In addition to histological examinations, cytological samples are also being evaluated with increasing frequency for the diagnosis of lung carcinoma.

OBJECTIVES

Possible applications of and techniques for cytological examinations are presented. Typical morphologies of primary lung cancer and metastatic disease are shown.

MATERIAL AND METHODS

Samples were obtained during bronchoscopy, serous effusion fluid, and fine-needle aspiration cytology. Special technical features of the cytological samples are discussed. Cytomorphology of pulmonary adenocarcinoma, squamous-cell carcinoma, and small-cell lung carcinoma are shown.

RESULTS

There are clear-cut diagnostic criteria for the main subtypes of primary lung carcinoma.

CONCLUSIONS

Cytological examination is a valuable addition to histology for lung carcinoma diagnostics.

Rehydration before wet fixation in conventional body fluid cytology - An 18-year experience

PURPOSE

In conventional cytology, preparation of a specimen by wet fixation for Papanicolaou stain is potentially subject to dry effect or cell loss which may make cytologic interpretation difficult or even impossible. We have been routinely making an additional smear for rehydration with normal saline (rehydration method) before wet fixation to overcome the above shortcomings.

METHODS

We reviewed malignant pleural effusion and ascites 15 cases each in our cytology laboratory over the past 1 year. Four slides of each specimen were made. Two were air-dried for Liu's stain (a Romanowsky stain) and the other two were wet-fixed for Papanicolaou stain. The air-dried smears were also served as retained cellularity control. One of the two wet-fixed smears was processed as a control of preservation of nuclear detail whereas the other one stayed air-dried for 10 minutes and then covered with normal saline (rehydration method) for 80 seconds before wet fixation.

RESULTS

There was minor cell loss (P = .032). The cells appeared larger with good preservation of nuclear detail (P < .0001 by two-sided Wilcoxon rank sum test) but no red blood cells retained on the slide after rehydration.

CONCLUSION

The rehydration method can effectively minimise cell loss, enlarge and preserve the cytological features of malignant cells with haemolysis. This method is simple, practical and good for cytological screening for tumour cells and interpretation especially in a bloody smear. We recommend that the rehydration method be part of traditional cytopreparatory work of wet fixation for Papanicolaou stain in conventional body fluid cytology.

Management of cytological material, pre-analytical procedures and bio-banking in effusion cytopathology

Serous effusion fluid is one of the most commonly encountered specimens in routine cytopathology practice. It provides invaluable information about the patient and the clinical status; but to get the most of it, specimen handling and processing must be carried out properly. Cytomorphology is the basis of a successful analysis which should complemented by ancillary tests when needed. A wide spectrum of ancillary techniques - ranging from immunocytochemistry and flow cytometry to different assays of molecular pathology - can be applied to serous effusions. This article describes the acquisition and management of serous effusion fluids, methods for preservation and transportation, different techniques of cytopreparation, application of immunocytochemistry, flow cytometry, and fluorescence in-situ hybridization (FISH), as well as DNA extraction for polymerase chain reaction (PCR) and next generation sequencing (NGS). Principles of bio-banking of effusion samples are also discussed which is getting more important in correlation with the developments in personalized medicine.

Liquid-Based Cytopathology Test: A Novel Method for Diagnosing Pulmonary Mucormycosis in Bronchial Brushing Samples

Background: Pulmonary mucormycosis, a relatively rare but severe pulmonary fungal disease with a high mortality rate, is difficult to diagnose in immunocompromised patients. Conventional cytopathology (CCP) examination of respiratory samples can help detect Mucorales, but its diagnostic sensitivity is poor. The aim of this study was to assess the first application of liquid-based cytopathology test (LCT) to detect Mucorales.

Methods: A total of 33 pairs of bronchial brushing samples from 27 patients diagnosed as pulmonary mucormycosis by fiberoptic bronchoscopy biopsy were prepared as slides using both CCP and LCT. LCT and CCP used the same cytology brush to obtain samples at the same site during the same time as the fiberoptic bronchoscopy biopsy. All samples were stained with Papanicolaou, GMS and PAS. CCP and LCT slides were evaluated from the rate of positive detection, 8 cytomorphological features and 7 background features.

Results: LCT-prepared slides showed a higher positive rate of Mucorales detection than CCP-prepared slides for Papanicolaou’s staining [28/33 (84.85%) vs. 15/33 (45.45%), p = 0.001] and for “special staining” with GMS and PAS [29/33 (87.88%) vs. 18/33 (54.55%), p = 0.003]. Clearer smear background and more distinct stereoscopic cytopathological features were observed in LCT. Messy yarn-like necrosis observed in conventionally prepared 75.76% (25/33) samples was cytomorphological suggestive for the diagnosis of mucormycosis.

Conclusion: This retrospective study suggests that LCT may be better than CCP to detect Mucorales in bronchial brushing samples from patients with pulmonary mucormycosis.

Value of automatic DNA image cytometry for diagnosing lung cancer

The present study aimed to investigate the diagnostic value of automatic DNA image cytometry (DNA-ICM) for diagnosing lung cancer. A total of three different types of samples from 465 cases were included: Bronchoalveolar lavage fluid (BALF), 386 samples; pleural effusion cases, 70 samples; and fine-needle aspiration procedures, 9 samples. Two methods, liquid-based cytology (LBC) and automatic DNA-ICM, were used to assess the samples, and the pathological results of 120/465 cases were reviewed. The results of DNA-ICM were compared with those of LBC and pathology. There were 57 cases of lung cancer without aneuploidy and 49 cases without evidence of malignant tumor, but with the presence of heteroploid cells. The positive diagnostic rate for BALF samples using LBC was significantly higher compared with that for DNA-ICM (P<0.05). No statistically significant difference was observed in the positive diagnostic rate between DNA-ICM and LBC in pleural effusion samples. For DNA-ICM in BALF, pleural effusion and all samples, no statistically significant differences were identified between the positive diagnostic rates of lung squamous carcinoma and lung adenocarcinoma. The positive diagnostic rate of LBC combined with DNA-ICM was not significantly improved. In non-small cell lung cancer (NSCLC) cases, the difference in the maximum value of DNA (DNAmax) was positively correlated with tumor stage (P<0.05), but no significant correlations were observed among DNA max, tumor type and tumor location. In small-cell lung cancer (SCLC) cases, no significant correlations were observed among DNAmax, tumor staging or tumor location. The differences in the DNAmax values of squamous cell carcinoma, adenocarcinoma, SCLC and NSCLC were not statistically significant. In the present study, the area under the receiver operating characteristic curve for LBC (0.936) was significantly greater compared with that for DNA-ICM (0.766) (P<0.05). DNA-ICM has medium diagnostic value in lung cancer, and the DNAmax was positively correlated with tumor stage in NSCLC. DNA-ICM may serve as a supplement to LBC, but it is not recommended as a sole procedure for lung cancer screening.

Comparison of Conventional Smear and Liquid-based Cytology Preparation in Diagnosis of Lung Cancer by Bronchial Wash and Transbronchial Needle Aspiration

Introduction:

Liquid-based cytology (LBC), initially developed for screening gynecologic specimens, is now being used in nongynecologic aspiration and exfoliative specimens. In this study, the diagnostic yield and utility of thin-prep (TP) was compared with conventional preparations to ascertain its utility in improving the diagnosis of respiratory lesions.

Materials and Methods:

Bronchial washings (BW) and transbronchial needle aspirates (TBNA) (bronchoscopy/endobronchial ultrasound-guided) from 70 consecutive patients of mediastinal masses and endo/peribronchial growths were included. The diagnostic yields of both conventional smears and thin-prep were compared. Immunocytochemistry (ICC) was performed on direct/cytospin smears of TBNA/BW and TP slides when the tumor could not be subtyped by morphology. Histopathologic correlation was done.

Results:

Although well-preserved morphological features and cleaner background in TP allowed accurate diagnosis of malignancies, diagnostic yield was comparable to conventional preparations. Immunocytochemistry was successfully employed on TP smears which helped in accurate subtyping of the tumors. Few shortcomings of TP smears were uneven distribution of cells, thick cell clusters, and inadequate cellularity.

Conclusion:

Liquid-based TP preparation is an effective diagnostic tool for respiratory tract cytology, however, results are comparable to conventional smears.

Liquid-based cytopathology test as a novel method to identify Aspergillus in patients with pulmonary aspergillosis

Conventional cytopathology examination of respiratory samples can aid in identifying Aspergillus but with poor sensitivity, so this study aimed to assess the potential of the liquid-based cytopathology test (LCT) for improving the identification of Aspergillus in respiratory samples following Papanicolaou's or Special staining with Grocott's methenamine silver or periodic acid-Schiff staining. Paired bronchial brushing samples (n = 54) and sputum samples (n = 117) from 171 patients with pulmonary aspergillosis were prepared as slides using either conventional cytopathology or SurePath LCT. LCT slides were generally superior to conventional slides, showing smaller cell monolayer surface area, clearer background and more distinct stereoscopic cytological features. For Papanicolaou's staining, LCT-prepared slides allowed a higher positive rate of Aspergillus identification than conventional slides for bronchial brushing samples (59.25% vs. 20.37%, P < 0.05) and sputum samples (29.05% vs. 8.55%, P < 0.05). Similarly, Special staining of LCT-prepared slides showed a higher positive rate of Aspergillus identification for bronchial brushing samples (83.33% vs. 57.41%, P < 0.05) and sputum samples (43.59% vs. 19.66%, P < 0.05). This preliminary study suggests that LCT may be better than conventional slide preparation for identifying Aspergillus in respiratory samples from patients with pulmonary aspergillosis.

Trends in Pleural Effusion Research

Background:

Research in pleural diseases has traditionally been neglected but is now growing.

Objectives:

This study aimed to analyze scientific research trends on pleural effusions over the last decades.

Method:

We conducted a bibliometric analysis of the Scopus database from its inception to March 2016, searching for original articles and reviews on “pleural effusion” (key word). Journal, year of publication, number of citations, authors and their affiliations, and the Hirsch (H)-index for some of these variables were recorded and analyzed.

Results:

A total of 15 982 documents were retrieved, of which half have been published in the last 18 years and a quarter during the last 8 years. Chest ranked first regarding the number of documents on pleural effusions (both absolute number and yearly rate) and their scientific relevance (H-index of 76). The United States had contributed the most to pleural research productivity (23%). American pulmonologists Dr Richard Light and Dr Steven Sahn exhibited the highest number of papers (206 and 156, respectively) and author H-indexes (44 and 38, respectively).

Conclusion:

There is growing research activity in the field of pleural effusions, which has gained relevance and visibility in clinical respiratory journals. The United States is the leader in quantity and quality of research productivity in pleural medicine.

Pre-analytical issues in effusion cytology

Effusions or body cavity fluids are amongst the most commonly submitted samples to the cytology laboratory. Knowledge of proper collection, storage, preservation and processing techniques is essential to ensure proper handling and successful analysis of the sample. This article describes how the effusions should be collected and proper conditions for submission. The different processing techniques to extract the cellular material and prepare slides satisfactory for microscopic evaluation are described such as direct smears, cytospins, liquid based preparations and cell blocks. The article further elaborates on handling the specimens for additional ancillary testing such as immunostaining and molecular tests, including predictive ones, as well as future research approaches.

Guidelines for the Cytopathologic Diagnosis of Epithelioid and Mixed-Type Malignant Mesothelioma: a secondary publication

OBJECTIVE

To provide practical guidelines for the cytopathologic diagnosis of malignant mesothelioma.

DATA SOURCES

Cytopathologists with an interest in the field involved in the International Mesothelioma Interest Group (IMIG) and the International Academy of Cytology (IAC) contributed to this update. Reference material includes peer-reviewed publications and textbooks.

RATIONALE

This article is the result of discussions during and after the IMIG 2012 conference in Boston, followed by thorough discussions during the 2013 IAC meeting in Paris. Additional contributions have been obtained from cytopathologists and scientists who could not attend these meetings, with final discussions and input during the IMIG 2014 conference in Cape Town.

Guidelines for the cytopathologic diagnosis of epithelioid and mixed-type malignant mesothelioma: Complementary Statement from the International Mesothelioma Interest Group, Also Endorsed by the International Academy of Cytology and the Papanicolaou Society of Cytopathology

OBJECTIVE

To provide practical guidelines for the cytopathologic diagnosis of malignant mesothelioma.

DATA SOURCES

Cytopathologists with an interest in the field involved in the International Mesothelioma Interest Group (IMIG) and the International Academy of Cytology (IAC) contributed to this update. Reference material includes peer-reviewed publications and textbooks.

RATIONALE

This article is the result of discussions during and after the IMIG 2012 conference in Boston, followed by thorough discussions during the 2013 IAC meeting in Paris. Additional contributions have been obtained from cytopathologists and scientists who could not attend these meetings, with final discussions and input during the IMIG 2014 conference in Cape Town.

Direct comparison of liquid-based and smear-based cytology with and without rapid on-site evaluation for fine needle aspirates of thoracic tumors

BACKGROUND

Liquid-based cytology (LBC) and rapid on-site evaluation (ROSE) are proposed to improve the quality of fine needle aspirates (FNA) and their diagnostic yield compared with conventional smear cytology (CSC). This prospective study directly compared outcomes of sonar-guided FNA of thoracic tumors supported by LBC, CSC, or CSC with ROSE.

METHODS

Three aspirates each for both LBC and CSC with separate 22G spinal needles in a randomized, alternating sequence during 64 transthoracic FNA of thoracic tumors were collected. Smears were prepared by cytology staff on site but evaluated with ROSE only when all six samples had been collected. If no diagnostic material was found on the first three CSC additional needle passes guided by ROSE were performed.

RESULTS

Final diagnoses were non-small cell lung cancer in 50 (78.1%), small cell lung cancer in 11 (17.2%), mesothelioma in 1 (1.6%), and inflammation in 2 cases (3.1%), respectively. LBC and CSC were diagnostic in 42 (65.6%) and 49 (76.6%) cases, respectively (P = 0.039), with both methods diagnostic in 41 cases (64.1%). Fifteen cases (23.4%) remained undiagnosed following three passes for CSC but 9 (14.1%) of these were diagnosed using FNA and ROSE with a total yield of 58 cases (90.6%; P < 0.001).

CONCLUSION

The diagnostic yield of transthoracic FNA submitted for LBC is significantly lower than with CSC when slides are prepared professionally. ROSE significantly increases the yield of transthoracic FNA.

Guidelines for cytopathologic diagnosis of epithelioid and mixed type malignant mesothelioma. Complementary statement from the International Mesothelioma Interest Group, also endorsed by the International Academy of Cytology and the Papanicolaou Society of Cytopathology

To provide practical guidelines for the cytopathologic diagnosis of malignant mesothelioma (MM). Cytopathologists involved in the International Mesothelioma Interest Group (IMIG) and the International Academy of Cytology (IAC), who have an interest in the field contributed to this update. Reference material includes peer-reviewed publications and textbooks. This article is the result of discussions during and after the IMIG 2012 conference in Boston, followed by thorough discussions during the 2013 IAC meeting in Paris. Additional contributions have been obtained from cytopathologists and scientists, who could not attend these meetings, with final discussions and input during the IMIG 2014 conference in cape town. During the previous IMIG biennial meetings, thorough discussions have resulted in published guidelines for the pathologic diagnosis of MM. However, previous recommendations have stated that the diagnosis of MM should be based on histological material only.[12] Accumulating evidence now indicates that the cytological diagnosis of MM supported by ancillary techniques is as reliable as that based on histopathology, although the sensitivity with cytology may be somewhat lower.[345] Recognizing that noninvasive diagnostic modalities benefit both the patient and the health system, future recommendations should include cytology as an accepted method for the diagnosis of this malignancy.[67] The article describes the consensus of opinions of the authors on how cytology together with ancillary testing can be used to establish a reliable diagnosis of MM.

Guidelines for the cytopathologic diagnosis of epithelioid and mixed-type malignant mesothelioma. Complementary statement from the International Mesothelioma Interest Group, also endorsed by the International Academy of Cytology and the Papanicolaou Society of Cytopathology

OBJECTIVE

To provide practical guidelines for the cytopathologic diagnosis of malignant mesothelioma.

DATA SOURCES

Cytopathologists with an interest in the field involved in the International Mesothelioma Interest Group (IMIG) and the International Academy of Cytology (IAC) contributed to this update. Reference material includes peer-reviewed publications and textbooks.

RATIONALE

This article is the result of discussions during and after the IMIG 2012 conference in Boston, followed by thorough discussions during the 2013 IAC meeting in Paris. Additional contributions have been obtained from cytopathologists and scientists who could not attend these meetings, with final discussions and input during the IMIG 2014 conference in Cape Town.