Utility of rapid onsite evaluation of touch imprint cytology from endoscopic and cholangioscopic forceps biopsy sampling (with video)

T, Manikandan A, Ravichandar S. Petals of rose: Application of rapid on-site evaluation in bronchoscopy

In present day scenario, procedures that are minimally invasive like FNAs and Core needle biopsies are on the rise. Rapid on-site evaluation (ROSE) is a laboratory service that assesses the cytomorphologic features from FNA smears or biopsy contact imprints in the biopsy room and can provide on the spot input and suggestions for the clinician through immediate cytological examination of the biopsy sample. ROSE also allows for a preliminary diagnosis, allowing for the requirement of additional material for ancillary studies. We are presenting two cases which highlights the merits of ROSE in cytological diagnosis.   In the first case, a thirty four year old male patient came with complaints of productive cough, breathlessness and fever. Bronchoscopic needle aspiration and biopsy was done with Rapid Onsite Evaluation. ROSE revealed two non-caseating epithelioid granulomas on the 4th pass. Bronchoscopic lymph node biopsy was non- contributory. With other clinical and biochemical parameters, diagnosis of Sarcoidosis was made. This case study underscores the significance of ROSE in arriving at the diagnosis.   In the other case, a fifty seven year old male patient came to hospital with productive cough and breathlessness (MMRC grade II). CT chest revealed features suggestive of bronchogenic carcinoma. ROSE was performed along with bronchial brush cytology in which presence of atypical cells with increased nuclear cytoplasmic ratio, nuclear hyperchromatism and nuclear molding was noted. On histopathological examination, it was diagnosed as a case of non-small cell carcinoma of lung – poorly differentiated type. This case proves the advantage of ROSE in avoiding repeated invasive procedures for the patient.

Clinical practice patterns in indirect peroral cholangiopancreatoscopy: outcome of a European survey

Background and aims  Indirect peroral cholangiopancreatoscopy (IPOC) is a relatively new diagnostic and therapeutic tool for biliopancreatic diseases. This international survey aimed to evaluate clinical practice patterns in IPOC among endoscopists in Europe. Methods  An online survey was developed comprising 66 questions on the use of IPOC. Questions were grouped into four domains. The survey was sent to 369 endoscopists who perform IPOC. Results  86 respondents (23.3 %) from 21 different countries across Europe completed the survey. The main indications for cholangioscopy were determination of biliary strictures (85 [98.8 %]) and removal of common bile duct or intrahepatic duct stones (79 [91.9 %]), accounting for an estimated use of 40 % (interquartile range [IQR] 25-50) and 40 % (IQR 30-60), respectively, of all cases undergoing cholangioscopy. Pancreatoscopy was mainly used for removal of pancreatic duct stones (68/76 [89.5 %]), accounting for an estimated use of 76.5 % (IQR 50-95) of all cases undergoing pancreatoscopy. Only 13/85 respondents (15.3 %) had an institutional standardized protocol for targeted cholangioscopy-guided biopsy sampling. IPOC with lithotripsy was used as first-line treatment in selected patients with bile duct stones or pancreatic stones by 24/79 (30.4 %) and 53/68 (77.9 %) respondents, respectively. Conclusions  This first European survey on the clinical practice of IPOC demonstrated wide variation in experience, indications, and techniques. These results emphasize the need for prospective studies and development of an international consensus guideline to standardize the practice and quality of IPOC.

High sensitivity of ROSE-supported ERCP-guided brushing for biliary strictures

Background and study aims  Endoscopic retrograde cholangiopancreatography (ERCP) plays a major role in biliary strictures, with brushing being a cheap and fast method to acquire a cytological specimen, despite a sensitivity around 45 %. Rapid on-site evaluation (ROSE) is widely used for endoscopic ultrasound-acquired cytological specimen adequacy, improving its sensitivity and specificity. Nevertheless, no study has evaluated its role for ERCP-guided brushing. Our aim was to assess the diagnostic yield of ERCP-guided brushing of biliary strictures when supported by ROSE. Patients and methods  This was a retrospective single-center study that included patients undergoing ERCP-guided brush cytology supported by ROSE for biliary strictures. Recorded data included patient clinical-radiological and ERCP features. Final diagnosis was determined after surgery, intraductal biopsy or adequate follow-up. The diagnostic yield was calculated and a subgroup analysis for factors associated with false-negative or true-positive results was performed. Results  Two hundred six patients were included, 57.3 % males, median age 72 years, 77.2 % having extrahepatic biliary strictures. Of the patients, 99 % had an adequate sample at ROSE after a mean of 2.6 passages. The diagnostic yield was accuracy 83 %, sensitivity 74.6 %, and specificity 98 %, positive and negative predictive values 98 % and 71 % respectively, with an area under the curve of 0.86. A diagnosis of cholangiocarcinoma was significantly more frequent among true-positive cases (68 % vs 46.8 %; P  = 0.04). Conclusions  This is the first study evaluating the use of ROSE as support for ERCP-guided brushing of biliary strictures, with a sensitivity far higher than those reported for brushing alone and at least comparable to those of more expensive and invasive techniques.

Touch preparation for rapid onsite evaluations of renal mass biopsies: concordance rate, pearls, and pitfalls

INTRODUCTION

Core needle biopsy (CNB) of renal masses has not been commonly performed because of the perceived low sensitivity until recent years. Rapid onsite evaluation (ROSE) using touch preparations (TPs) has the potential to improve the yield of CNB, although it can be challenging because of the diverse morphology of various types of renal tumors and native cells.

MATERIALS AND METHODS

We retrospectively reviewed percutaneous CNBs of renal masses with ROSE using TPs. ROSE findings were correlated with diagnoses on CNBs.

RESULTS

Among the 165 cases identified between August 2016 and August 2019, CNB led to definitive diagnoses in 82.4% (136 of 165) cases. These included renal cell carcinomas (RCCs) (n = 113, 68.5%), benign neoplasms (n = 14, 8.5%), urothelial carcinomas (n = 6, 3.6%), metastatic carcinomas (n = 2, 1.2%) and 1 case of lymphoma (0.6%). Eight cases were indeterminate, including 2 cases positive for oncocytic neoplasm, 2 cases suspicious for RCC, and 4 cases with atypical features. Twenty-one (12.7%) CNBs were negative for tumor. ROSE interpretations for these cases were: malignant (n = 18, 10.8%); positive for neoplasm (n = 6, 3.6%); atypical/lesional/adequate not otherwise specified (n = 113, 68.5%); negative (n = 19, 11.5.0%); and unsatisfactory (n = 9, 5.5%). The overall concordance rate between ROSE and the final CNB diagnoses was 87.3%.

CONCLUSIONS

Renal mass CNBs revealed a subset of non-surgical conditions in addition to RCCs. ROSE using TPs showed a high concordance rate with CNB results. Proximal tubular cells, macrophages, and angiomyolipomas are common pitfalls, whereas vacuolated cytoplasm and background are helpful features to confirm low-grade RCCs.

Challenging biliary strictures: pathophysiological features, differential diagnosis, diagnostic algorithms, and new clinically relevant biomarkers - part 1

It is frequently challenging to make the correct diagnosis in patients with biliary strictures. This is particularly important as errors may have disastrous consequences. Benign-appearing strictures treated with stents may later be revealed to be malignant and unnecessary surgery for benign strictures carries a high morbidity rate. In the first part of the review, the essential information that clinicians need to know about diseases responsible for biliary strictures is presented, with a focus on the most recent data. Then, the characteristics and pitfalls of the methods used to make the diagnosis are summarized. These include serum biomarkers, imaging studies, and endoscopic modalities. As tissue diagnosis is the only 100% specific tool, it is described in detail, including techniques for tissue acquisition and their yields, how to prepare samples, and what to expect from the pathologist. Tricks to increase diagnostic yields are described. Clues are then presented for the differential diagnosis between primary and secondary sclerosing cholangitis, IgG4-related sclerosing cholangitis, cholangiocarcinoma, pancreatic cancer, autoimmune pancreatitis, and less frequent diseases. Finally, algorithms that will help to achieve the correct diagnosis are proposed.