copy of maastricht 19062018v1 169 · §enlarged or fdg-avid mediastinal lymph node (primarly in the...
TRANSCRIPT
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Cytology in EBUS
Myriam Remmelink MD, PhDDpt Surgical Pathology, Brussels
CONFLICT OF INTERESTS:
§ To comply with UEMS CME regulations
§ No conflict of interests
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AGENDA
§ Introduction§ Indications§ Material§ Technical considerations§ Cytologic examination§ Pitfalls§ Ancillary studies§ Conclusions05.07.18 3
EBUS - TBNA
§ Endobronchial Ultrasound-Guided Transbronchial NeedleAspiration
§ Diagnostic modality that can help provide pathologicalsampling of lung or mediastinal lesions
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Echo-endoscopeEBUS - TBNA
Echo-endoscopeEBUS - TBNA
EBUS - TBNA
EBUS - TBNA
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EBUS-TBNAEBUS - TBNA
3-5 for ech targeted lesionpasses
EBUS-TBNA
3 -5 passes / target
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• Minimally invasive• Safe• Cost effective• Real time image guidance • Provides high yield specimens
• Challenging : experience &expertise• Cannot be used to access alllymph node• May procure sample withbronchial contamination• May have non diagnostic resultsthat need additional sampling
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The IASLC lymph node map, group of lymph node stations into zones
MAIN INDICATIONS
§ (Re) Staging of lung cancer patients
§ Diagnosis of lymphadenopathy
§ Enlarged or FDG-avid mediastinal lymph node(primarly in the anterior and superior mediastinum)
§ Mass lesion within the mediastinum or centrally located inthe lung
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COMPLICATIONS
§ Low complication rate (<1%), no mortality¨ Bleeding¨ Infection¨ Pneumomediastinum¨ Pneumothorax
§ Safe
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DIAGNOSTIC PERFORMANCES
Very high specificityclose to 100%
in most studies
The sensitivity varies depending on whetherhistological or clinical follow upis used for
comparison
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DIAGNOSTIC PERFORMANCES
SAMPLING Obtaining good samples
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GOLD STANDARD : MEDIASTINOSCOPY
Specificity : 100% both
Sensibility : Best in mediastinoscopy : 91%
PRICE ! EBUS Mediastinoscopy
Morbidity <1% 0,5-2,5%
Mortality 0 0,02%
SPECIMEN COLLECTION AND PROCESSING
§ In order to optimize aspirated material, all residualmaterial in the needle and syringue, and the excessmaterial on slides or in blood clots should be collected forpotential ancillary studies
§ FNA material can be used to prepare direct smear, cellblocks
§ And submit to microbiology culture, molecular studies ifneeded05.07.18 19
ROSE OR NOT?
§ Rapid on site evaluation
§ Done by cytologist ( or telecytology ! )
§ Can provide feedback regarding adequacy of the specimen :QUANTITATIVE AND QUALITATIVE
§ Improve the diagnostic yield
§ Allow appropriate triage of the procured specimen05.07.18 20
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ROSE
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EBUS TBNA needle are long and have multiple movable parts
Thus more than one person may be needed duringslide preparation :
One can hold the needle tip and guide expelledmaterialThe other can hold the handle and plunge the syringue filled with air
SLIDE PREPARATION
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1 slide/passeAir dryed , Diff Quick staining
Formalin 10% bufferedCell block
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TRIAGE
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(Rose)Cellblock
3. Infection? Sterile container for microbiology culture
4.Lymphoproliferative disorder? Medium (RPMI) for flow cytometry
5. Molecular testing
DIFFICULTIES
§ Lack of standardized criteria
§ Wide variety of mediastinal/lung lesions to consider(always have clinical data!!!)
§ Potential contamination of the needle with normal ordysplastic bronchial elements
§ Lack of ancillary studies during ROSE05.07.18 26
DIAGNOSTIC DIFFICULTIES AND CHALLENGES
§ Non diagnostic EBUS-TBNA specimen can still be hypercellular
§ Due to numerous reactive bronchial epithelial cells, cartilage, mucoidcells
§ The high cellularity of EBUS-TBNA makes these cases difficult toscreen both at the time of Rose evaluation and final evaluation
§ Thus the focus is more on qualitative , not quantitative features
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PRACTICAL APPROACH TO EVALUATION
§ Adequate : YOU SEE SOMETHING§ Tumor cells OBVIOUS!, no rareOr§ Granulomatous inflammationOr§ Sufficent (?) number of lymphocytes and/or pigment laden
macrophages
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Sufficent?No definitive criteria but important to avoid false negative!!One slide with lymphocytes comprising 30% or more of thecellsMore than 40 lympho/HPF in most cellular area
LYMPHOCYTE COUNTS (DQ STAIN, X400)
<40 =40 >40
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ANTHRACOTIC PIGMENT LADEN MACROPHAGES
Helpful indicator of lymph node samplingDD : melanin, graphite, hemosiderin pigment
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DIAGNOSTIC DIFFICULTIES AND CHALLENGES
§ There is currently no universally accepted welldefined adequacy criteria for EBUS-TBNAspecimens
§ Pitfalls in evaluation of adequacy in EBUS-TBNA
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Bland neoplasms Mimic benign bronchial epithelial cells
Single malignant cells Difficult to identifyReactive changes withinbronchial epithelium
Mimic malignancy
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BLAND NEOPLASM
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SINGLE ATYPICAL CELLS
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REACTIVE CHANGES
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ADEQUACY OF THE SPECIMEN
§ CRITICAL
§ Non diagnostic cases >< negative case
§ Minimize the risk of false negative
§ No well-established adequacy criteria with regard to thenumber of lymphocytes needed for a negative diagnosis
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ADEQUACY
§ Major problem in EBUS : contamination!!! (bronchial cells )
§ Do I have sufficient lymphocytes to indicate that the lymph node isadequately sampled?
§ ? Germinal center fragments and clusters of anthracotic pigment-laden macrophages
§ Is there are malignant cells or granuloma among all the benign andreactive cells?
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Adequate§ Adequate specimen =
material that explains the patient’s lymphadenopathy
§ Malignant cells?§ Granulomatous
inflammation?§ Suffisant lymphoid cells
Inadequate§ Abundant bronchial
contamination§ And/or§ Blood§ Without lymphoid cells ,
granulomatous inflammation, malignant cells
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ADEQUACY OF THE SPECIMEN
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INADEQUATE
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CLINICAL MANAGEMENT
Mediastinallymphadenopathy>1 cm of FDG avid on
PET scan
EBUS TBNA
Malignant
Treatment
Indeterminate or non diagnostic
Mediastinoscopy
Benign
Médiastinoscopy Specific diagnosis
NON DIAGNOSTIC OR UNSATISFACTORY
§ Mediastinoscopy
§ Could be informative!
§ Biologic properties of the lesion!§ Lymphomas!
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NORMAL COMPONENTS
§ Recognizing normal components is CRITICAL to avoid anoverdiagnosis or misdiagnosis in these specimens
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Check adequacy
Confusing !!!!!
LYMPHOCYTES
§ Benign and reactive lymphocytes can be difficultto distinguish from§ Small cell lymphoma§ Thymic lesions§ Small blue cell tumors
§ Clinical correlation !!!§ Discussion with the clinician§ Flow cytometry, immunohistochemistry05.07.18 44
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BENIGN BRONCHIAL CONTAMINANTS
§ EBUS-TBNA needle traverses the bronchial wall§ CONTAMINATION§ Bronchial cells : presence of cilia on the apical surface arising from a
terminal bar
DD carcinoma
§ Nuclear polymorphism, hyperchromasia, nuclear enlargment05.07.18 45
CONTAMINATION , BACKGROUND MATERIAL , ARTIFACTS
§ Bronchial contamination gives rise to specimens with high baseline cellularity even in non diagnostic samples
§ Bronchial contamination such as reactive or metaplasticbronchial epithelial cell , mucous and cartilage is important to recognize because in the absence of lymphoid cells, granulomas or tumor cells, it indicates a non diagnostic sample
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CONTAMINATION , BACKGROUND MATERIAL , ARTIFACTS
§ The main type of background include blood, mucinous, necrotic,inflammatory, tigroid and lymphoid
§ Artefactual distorsion such as air drying or crush artifact
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CONTAMINATION , BACKGROUND MATERIAL , ARTIFACTS
§ Goblet cell metaplasia >< signet ring type adenocarcinoma
§ Clustering, ciliated cell, lack pleomorphism or necrosis
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CONTAMINATION , BACKGROUND MATERIAL , ARTIFACTS
Mucoid material >< mucinous adenocarcinoma
§ Dirty, entrapped bronchial cells, no cells with mucinous cytoplasmor targetoid vacuoles with central mucin droplet
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CONTAMINATION , BACKGROUND MATERIAL , ARTIFACTS
§ Lymphoid cells crushed >< small cell carcinomaI
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CONTAMINATION
§ Key features of benign or reactive cells :
§ Scant cells with atypia§ Lack of necrosis§ Lack of mitotic figures§ Spectrum of changes from benign to reactive (not two distinct
different populations)
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CONTAMINATION
§ Caution : § Poor fixation/ staining§ Obscuring inflammation§ Scant cellularity
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GRANULOMATOUS INFLAMMATION
§ First : Are you sure it is a § granuloma?
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GRANULOMATOUS INFLAMMATION
§ Second : type of granuloma?
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Correlation with• special stains• microbiology culture results• clinical findings
PULMONARY EPITHELIAL NEOPLASMS
§ Diagnosing NSCLC can be challenging given the cytomorphological overlap with
§ Granulomatous inflammation, § Reactive bronchial epithelial atypia,§ Metastatic extrapulmonary carcinomas
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PULMONARY EPITHELIAL NEOPLASMS
§ Diagnosing NSCLC can be challenging given the cytomorphological overlap with
§ Granulomatous inflammation, IHC§ Reactive bronchial epithelial atypia,§ Metastatic extrapulmonary carcinomas IHC
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PULMONARY EPITHELIAL NEOPLASMS
§ Small cell carcinomas can be difficult to differentiate from
§ Benign lymphocytes with crush artifacts, lymphoma, IHC
§ Neuroendocrine neoplasms§ NSCLC (basaloid carcinoma, LCNEC) IHC
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PULMONARY EPITHELIAL NEOPLASMS
§ Collaboration with clinicians to avoid loss of material!!!
§ Dont forget : Sparing of material for molecular studies in case of ADC, NSCLC favor ADC NSCLC-NOS
§ EBUS-TBNA is frequently used as the primary diagnostic modalities for establishing a diagnosis and for staging the patient
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ALGORITHM FOR THE WORK-UP OF NON RESECTIONLUNG CANCER SPECIMEN J Thorac Oncol, 2011
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IMMUNOHISTOCHEMICAL TYPING & CLASSIFICATION IASCL/ATS/ERS OF NSCLC
+
Moleculartesting
Moleculartesting
No test
WHO 2015
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NON PULMONARY METASTATIC CARCINOMAS
§ Metastatic non pulmonary carcinomas can overlap in cytomorphologywith lung carcinomas which can make difficult to diagnose in EBUS-TBNA
§ Especially in patients with a prior history of another tumor or in patients without a lung mass
§ It is important to obtain sufficient material for ancillary studies as IHC and potential molecular studies, in select tumor when one isconsidering a metastatic non pulmonary carcinomas
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NON PULMONARY METASTATIC CARCINOMAS
§ Careful attention devoted to clinical history and atypical morphology or the immunoprofile should raise suspicion of a non pulmonarycarcinoma
§ Site specific staining can help to determine the site of origin for a variety of non pulmonary adenocarcoma
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ADENOCARCINOMA AND IMMUNOPROFILE
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Metastatic papillary carcinoma can mimic primary pulmonary adenocarcinomawith papillary features (TTF1 positivity in both!)
METASTATIC NON PULMONARY SQUAMOUS CELLCARCINOMA
§ Paucity of site-specific markers that we can use to determine their site of origin
§ P16 ( + in situ hybridation for HPV)
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NON EPITHELIAL NEOPLASM
§ Lymphomas!!!
§ And other hematologic malignancies
§ Mesenchymal tumors
§ Germ cells tumors
§ Melanomas
§ Mesothelioma05.07.18 67
Sufficient material!Ancillary studies!
NON EPITHELIAL NEOPLASM
§ Lymphomas!!! And other hematologicmalignancies
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Flow cytometryImmuno-Cyto-chemistry
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THYMIC LESIONS AND NEOPLASMS
§ Limited reports
§ Limited to patient for whom a surgery is not feasible
§ Cytologic examination of thymoma alone cannot reliablyclassify the various subtypes of thymomas nor can theybe used to determine invasion
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TAKE HOME MESSAGE 1
§ ROSE § Quantitative and qualitative examination
§ Tumor cells OBVIOUS!, no rareOr§ Granulomatous inflammation Or§ Sufficent (?) number of lymphocytes and/or pigment
laden macrophages
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TAKE HOME MESSAGE 2
§ Contamination!
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TAKE HOME MESSAGE 3
§ Collaboration!
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LITTERATURE
Endobronchial ultrasound-transbronchial needle aspiration (EBUS/TBNA): a diagnostic challenge for mediastinal lesions.
§ Divisi D, Zaccagna G, Barone M, Gabriele F, Crisci R.
§ Ann Transl Med. 2018 Mar;6(5):92.
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)-from morphology to molecular testing.
§ Righi L, Franzi F, Montarolo F, Gatti G, Bongiovanni M, Sessa F, La Rosa S.
§ J Thorac Dis. 2017 May;9(Suppl 5):S395-S404.
Guideline for the acquisition and preparation of conventional and endobronchial ultrasound-guided transbronchial needleaspiration specimens for the diagnosis and molecular testing of patients with known or suspected lung cancer.
§ van der Heijden EH, Casal RF, Trisolini R, Steinfort DP, Hwangbo B, Nakajima T, Guldhammer-Skov B, Rossi G, Ferretti M, Herth FF, Yung R, Krasnik M; World Association for Bronchology and Interventional Pulmonology, TaskForce on Specimen Guidelines.
§ Respiration. 2014;88(6):500-17..
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