The role of endobronchial ultrasound guided transbronchial needle aspiration cytology in the investigation of mediastinal lymphadenopathy and masses, the North Tees experience

Insufficient endobronchial ultrasound-guided transbronchial needle aspiration specimens. When and why? The analysis of criteria and reasons behind the insufficient specimens

BACKGROUND

The classification terminology systems for pulmonary cytology specimens have recently emerged. Inadequate samples, classified as "nondiagnostic," raise challenges in determining the threshold of cell numbers and the risk of malignancy (ROM).

METHODS

The study retrospectively reviewed 248 endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) samples: 46 insufficient samples, 60 low cellularity samples, and 142 adequate samples. Characteristics as cellularity, number of benign and malignant cells, and background features were assessed. Receiver operating characteristic curve analysis was performed to establish cell sufficiency thresholds for the diagnosis.

RESULTS

Out of the 248 samples analyzed, 108 were classified as benign, 94 as malignant, and 46 as insufficient. The study found that the cellularity thresholds for diagnosis in cell blocks and cytological samples were ≥50 cells and ≥100 cells, respectively. The thresholds for tumor cell counts were ≥1 - 10 cells for both types of cells, respectively. Considerably, some low cellularity samples were initially classified as insufficient despite meeting the diagnostic thresholds upon revision. The ROM varied across sample categories, with insufficient samples having a ROM of 10.9%, benign samples 15.7%, suspicious samples 92.0%, and malignant samples 100%.

CONCLUSION

Insufficient EBUS-TBNA samples raise challenges in diagnosis and management. This study identified the root cause of insufficient samples, including factors related to humans, diagnostic methods, sampling, and laboratory processing. By understanding the root causes, diagnostic recommendations can be developed to improve the diagnostic process. The findings emphasize the importance of standardized classification and terminology systems for clear communication among healthcare professionals and institutions, ultimately improving patient care and enabling quality assurance measures.

Role of EBUS-TBNA/EUS-FNA and mass spectrometry for diagnosis and typing of lymph node amyloidosis: 10-year experience in two tertiary care academic centers

BACKGROUND

The objectives of this study were to investigate the utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)/endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for the diagnosis of amyloidosis coupled with the feasibility of mass spectrometry (MS) for amyloid subtyping.

METHODS

All patients who had amyloid diagnosed by EBUS-TBNA/EUS-FNA at two tertiary care centers from 2011 to 2020 were retrieved along with the MS subtype, clinical findings, and outcomes.

RESULTS

Eight patients were included: seven underwent EBUS-TBNA of mediastinal lymph nodes, and one underwent EUS-FNA of a periportal lymph node. Ages ranged from 37 to 79 years (median, 69 years), with equal numbers of men and women. Presenting clinical history included one case each of follicular lymphoma, lymphoplasmacytic lymphoma, rheumatoid arthritis, possible sarcoid, cirrhosis, and chronic renal insufficiency, and one case each of suspected pulmonary and cardiac amyloidosis. All cases showed waxy, amorphous material on direct smears (n = 5) or ThinPrep slides (n = 3), which were confirmed as amyloid on Congo Red staining. Immunohistochemistry showed dominant lambda staining in two of three cases. MS was performed in all cases and identified five of the light-chain (AL) type, one of the heavy-chain/AL type, and two suggestive of AL amyloidosis. Bone marrow biopsy performed in seven patients demonstrated that three had monoclonal plasma cells and one had lymphoplasmacytic lymphoma. Two of four patients with systemic amyloidosis received chemotherapy and remained alive, whereas three with localized disease remained stable under observation.

CONCLUSIONS

EBUS-TBNA/EUS-FNA is effective for amyloidosis diagnosis and provides adequate material for ancillary tests, including MS, which can identify the precursor amyloidogenic protein, leading to appropriate patient management.

EBUS-TBNA: A 2-Year Experience from a Tertiary Pathology Centre with Cyto-Histological Correlation

INTRODUCTION

Endoscopic ultrasound-guided fine-needle aspiration and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) methods are expanding due to their minimally invasive nature using real-time image guidance, a low incidence of complications, and a diagnostic rate ranging from 89% to 93.6%. The application of EBUS-TBNA was able to downgrade 40% of patients with suspicion of stage III lung cancer on PET scan.

METHODS

In the present study, we analysed the diagnostic outcomes of EBUS cytology at the Laboratory of Pathology, Fimlab Laboratories, Tampere, Finland, during a 2-year period. In our analysis, 1176 EBUS samples from 486 patients that underwent EBUS-TBNA in Tampere University Hospital (TAYS) from January 2017 to December 2018 were reviewed. The mean age of the patients was 64 ± 14 (SD) years with the age range from 19 to 90 years. Cytospin cytology slides stained by Papanicolaou stain and cell blocks were performed in each sample. Further immunohistochemical stains were ordered by the pathologist on demand.

RESULTS

The diagnostic yield was 89.5% and the diagnostic accuracy was 77.9% in the present study. The sensitivity for malignancy in EBUS-TBNA diagnosis was 95.69% and the negative predictive value 96.75%. Cyto-histopathological diagnosis correlation was 54.7% (95% confidence interval [CI]: 40.6%-66.4%, p < 0.001), and the histological accuracy compared to the exact original diagnosis was 43.5%. When considering the histological diagnoses that support the original diagnosis, the correlation was 61.3% (95% CI: 48.4%-71.5%, p < 0.001) and the accuracy was 72.2%. The overall inadequate rate of EBUS-TBNA samples in this study was 10.5%.

CONCLUSIONS

The EBUS-TBNA diagnostic yield, diagnostic accuracy, and inadequate rate in the present study are in line with previously published studies.

Cytological preparations for molecular analysis: A review of technical procedures, advantages and limitations for referring samples for testing

Minimally invasive procedures such as endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) must yield not only good quality and quantity of material for morphological assessment, but also an adequate sample for analysis of molecular markers to guide patients to appropriate targeted therapies. In this context, cytopathologists worldwide should be familiar with minimum requirements for refereeing cytological samples for testing. The present manuscript is a review with comprehensive description of the content of the workshop entitled Cytological preparations for molecular analysis: pre-analytical issues for EBUS TBNA, presented at the 40th European Congress of Cytopathology in Liverpool, UK. The present review emphasises the advantages and limitations of different types of cytology substrates used for molecular analysis such as archival smears, liquid-based preparations, archival cytospin preparations and FTA (Flinders Technology Associates) cards, as well as their technical requirements/features. These various types of cytological specimens can be successfully used for an extensive array of molecular studies, but the quality and quantity of extracted nucleic acids rely directly on adequate pre-analytical assessment of those samples. In this setting, cytopathologists must not only be familiar with the different types of specimens and associated technical procedures, but also correctly handle the material provided by minimally invasive procedures, ensuring that there is sufficient amount of material for a precise diagnosis and correct management of the patient through personalised care.

Unusual diagnoses made by convex-probe endobronchial ultrasound-guided transbronchial needle aspiration

Endobronchial ultrasound-guided transbronchial needle biopsy (EBUS-TBNA) has proven to be an effective and minimally invasive tool to diagnose and stage lung cancer. However, its use for the diagnosis of rare mediastinal and lung pathologies has been rarely described. Hereby we describe a retrospective chart review of our EBUS-TBNA database for unusual diagnosis made between July 2012 and October 2016. Those conditions considered unusual for EBUS-TBNA diagnosis were identified and their medical records reviewed.

The Lung in Dysregulated States of Humoral Immunity

In common variable immunodeficiency, lung manifestations are related to different mechanisms: recurrent pneumonias due to encapsulated bacteria responsible for diffuse bronchiectasis, diffuse infiltrative pneumonia with various patterns, and lymphomas, mostly B cell extranodal non-Hodgkin type. The diagnosis relies on significant serum Ig deficiency and the exclusion of any primary or secondary cause. Histopathology may be needed. Immunoglobulin (IgG) replacement is crucial to prevent infections and bronchiectasis. IgG4-related respiratory disease, often associated with extrapulmonary localizations, presents with solitary nodules or masses, diffuse interstitial lung diseases, bronchiolitis, lymphadenopathy, and pleural or pericardial involvement. Diagnosis relies on international criteria including serum IgG4 dosage and significantly increased IgG4/IgG plasma cells ratio in pathologically suggestive biopsy. Respiratory amyloidosis presents with tracheobronchial, nodular, and cystic or diffuse interstitial lung infiltration. Usually of AL (amyloid light chain) subtype, it may be localized or systemic, primary or secondary to a lymphoproliferative process. Very rare other diseases due to nonamyloid IgG deposits are described. Among the various lung manifestations of dysregulated states of humoral immunity, this article covers only those associated with the common variable immunodeficiency, IgG4-related disease, amyloidosis, and pulmonary light-chain deposition disease. Autoimmune connective-vascular tissue diseases or lymphoproliferative disorders are addressed in other chapters of this issue.

Understanding local performance data for EBUS-TBNA: insights from an unselected case series at a high volume UK center

BACKGROUND

We reviewed the diagnostic performance of endobronchial ultrasound transbronchial aspiration (EBUS-TBNA) on an unselected large cohort of patients who underwent the procedure in our institution in the past 3 years and to compare against published standards and existing literature.

METHODS

All consecutive patients who underwent EBUS from January 2013 to December 2015 were included in the retrospective analysis, with a minimum of 6 months of clinico-radiological follow up. For assessing EBUS-TBNA performance, patients were analysed in three subgroups based on the indication for the EBUS-TBNA: in investigation of isolated mediastinal and/or hilar lymphadenopathy (IMHL), in staging of suspected or confirmed non-small cell lung cancer (NSCLC) and in making a tissue diagnosis in suspected thoracic or extrathoracic cancer. For patients subjected to EBUS-TBNA for staging in suspected lung cancer, accuracy of EBUS was measured by its ability to determine the true N2 stage.

RESULTS

A total of 1,656 lymph nodes and 138 peribronchial/peritracheal masses were sampled in 940 patients over the study period. The prevalence of reactive lymphadenopathy was 34%. The overall sensitivity to detect pathological disease was 81.6% (95% CI: 74.2-87.6%) whilst NPV was 74.8% (95% CI: 65.2-82.8%). Amongst patients who underwent EBUS-TBNA for staging purposes, the sensitivity for N2 staging was 83.7% (95% CI: 76.2-89.6%) and NPV was 81.6% (95% CI: 73.2-88.2%). The prevalence of N2 disease was 58%. In the subgroup of patients who proceeded to surgical sampling, the sensitivity was higher with the N2/N3 disease prevalence of 67.4%. The sensitivity of EBUS-TBNA to make a tissue diagnosis of thoracic or extrathoracic cancer was 88% (95% CI: 85.1-90.5%) and a NPV of 62% (95% CI: 54.7-69.0%). The disease prevalence was 83.6%.

CONCLUSIONS

This retrospective study of a large volume of patients represents real life practice and provides an accurate representation of the typical cohort of patients referred in for EBUS-TBNA to the general respiratory physician in UK. Our study highlights the pitfalls in collecting and analyzing data but also demonstrates how they can be used to improve service performance.

The role of endobronchial ultrasound-guided fine needle aspiration in the diagnosis of pleural mesothelioma

OBJECTIVE

The aims of the present study were to investigate the role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis of malignant pleural mesothelioma (MPM), and to identify specific clinical settings in which this procedure can be recommended.

METHODS

We retrospectively reviewed the clinical and pathological files of patients having undergone EBUS-TBNA from February 2011 to October 2014 to investigate thoracic lesions. Among 736 patients, we identified four of them with a diagnosis of MPM achieved primarily through EBUS-TBNA. The diagnosis was made on formalin-fixed paraffin-embedded cell blocks, by checking the expression of mesothelial and carcinomatous-specific markers.

RESULTS

In all patients, the collected tissue was adequate, and the histological analysis in association with immunohistochemistry led us to the diagnosis of malignant pleural mesothelioma. In three patients, the diagnosis of mesothelioma was clinically suspected, as patients presented with diffuse pleural thickening. In two patients, videothoracoscopy was not possible owing to the 'dry' presentation of the pleural disease and the site of thickening. In this setting, EBUS-TBNA was considered, at a multidisciplinary consensus meeting, as the most adequate available method to obtain a histological diagnosis.

CONCLUSION

EBUS-TBNA may be a valuable diagnostic technique in the field of pleural pathology in selected clinical settings. More specifically 'dry' mesothelioma forming para-tracheal nodules or masses not accessible by surgery or by computed tomography/ultrasonogaphy-guided needle biopsy constitutes a good indication to perform EBUS-TBNA.

EGFR testing and the CAP/IASLC/AMP lung cancer biomarker testing guidelines: knowledge gaps and future directions

SUMMARY 

Developments in predictive molecular testing and personalized therapy of lung cancer have recently called for a major change in the histological and cytological activity requiring the pathologist to strictly connect with pulmonologists, oncologists and molecular biologists to improve patient management. Different clinical trials established that tyrosine kinase inhibitor therapy is superior to chemotherapy, when patients harbor EGFR mutations. Similarly, the patients whose lung carcinoma carries ALK fusion genes consistently respond to ALK inhibitors. These improvements have led to the understanding that the morphological diagnosis of lung adenocarcinoma requires a multidisciplinary approach; even more recently the College of American Pathologists, the International Association for the Study of Lung Cancer and the Association for Molecular Pathology encouraged to develop international guidelines for lung cancer biomarker testing. This paper summarizes the practical impact of these guidelines, focusing on the pathologist's role in daily EGFR testing practice.

Liquid-Based Cytology Preparation Can Improve Cytological Assessment of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration

OBJECTIVE

This study investigated whether liquid-based cytology (LBC) can improve diagnostic values of cytological assessment of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).

STUDY DESIGN

A cohort of 600 cases in West China Hospital was prospectively studied from June 2012 to September 2013. EBUS-TBNA was carried out in outpatients under local anesthesia and moderate sedation. The procedure was performed with an echobronchoscope (BF-UC160F-OL8, Olympus, Tokyo, Japan). Histological cores were stained with hematoxylin and eosin for further study. Additional immunohistological analysis was performed for establishing a reliable diagnosis when necessary. Aspirates were smeared on glass slides and separate aspirates were processed by the monolayer SurePath method.

RESULTS

In total, 480 malignant tumors and 120 benign lesions were confirmed by histological examination. The sensitivity of SurePath liquid-based preparations and conventional smears was 82.1 and 56%, and the specificity was 87.5 and 82.5%, respectively. The combined specificity was 100%. Positive predictive values of the two groups were 96.3 and 92.8%, whereas negative predictive values were 54.9 and 31.9%, respectively. The difference between the two groups was significant (p < 0.001).

CONCLUSIONS

LBC preparation can improve cytological assessment of EBUS-TBNA. Histological study is necessary in cases in which the cytological diagnosis is obscure.

Malignancy risk associated with the EBUS-FNA diagnostic categories nondiagnostic, benign, atypical, suspicious for malignancy, and malignant for mediastinal lymph node aspirate specimens

INTRODUCTION

Endobronchial ultrasonography-guided transbronchial fine-needle aspiration (EBUS-TBFNA) is used for preoperative staging of primary lung carcinomas. Published sensitivity and specificity are up to 86% and 100%, respectively. Diagnostic categories used by many cytopathologists are nondiagnostic, benign, atypical, suspicious, and malignant. Little information exists about the risk of malignancy associated with each of these categories.

MATERIALS AND METHODS

Records of the Department of Pathology at the University of Utah were searched for all EBUS-TBFNAs of mediastinal and pulmonary hilar lymph nodes. Only cases with surgical follow-up were included in this study. For each diagnostic category (nondiagnostic, benign, atypical, suspicious, and malignant), the percentage of cases proven to be malignant was calculated following correlation of cytologic and surgical diagnoses. Positive and negative predictive values were calculated. For calculation of accuracy statistics, atypical cases were considered benign and suspicious cases were classified as malignant.

RESULTS

For this study, 136 EBUS-TBFNAs of lymph nodes were obtained with adequate surgical follow-up. Risk of malignancy for nondiagnostic specimens was 42%, benign specimens 32%, atypical specimens 40%, suspicious specimens 83%, and malignant specimens 84%. Positive predictive value was 84%, and negative predictive value was 68%.

CONCLUSIONS

The categories stratified malignancy risk ranging from a low of 32% for benign to 84% for malignant. The categories suspicious and malignant had similar malignancy risks. Atypical aspirates had a higher malignancy risk than benign aspirates did. Nondiagnostic aspirates had a malignancy risk similar to that of atypical aspirates. This scoring system may aid in treatment planning and patient counselling.

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.

Role of the pulmonologist in ordering post-procedure molecular markers in non-small-cell lung cancer: implications for personalized medicine

In the growing era of personalized medicine for the treatment of non-small-cell lung cancer (NSCLC), it is becoming increasingly important that sufficient quality and quantity of tumor tissue are available for morphologic diagnosis and molecular analysis. As new treatment options emerge that might require more frequent and possibly higher volume biopsies, the role of the pulmonologist will expand, and it will be important for pulmonologists to work within a multidisciplinary team to provide optimal therapeutic management for patients with NSCLC. In this review, we discuss the rationale for individualized treatment decisions for patients with NSCLC, molecular pathways and specific molecular predictors relevant to personalized NSCLC therapy, assay technologies for molecular marker analysis, and specifics regarding tumor specimen selection, acquisition, and handling. Moreover, we briefly address issues regarding racial and socioeconomic disparities as they relate to molecular testing and treatment decisions, and cost considerations for molecular testing and targeted therapies in NSCLC. We also propose a model for an institution-based multidisciplinary team, including oncologists, pathologists, pulmonologists, interventional radiologists, and thoracic surgeons, to ensure adequate material is available for cytological and histological studies and to standardize methods of tumor specimen handling and processing in an effort to provide beneficial, individualized therapy for patients with NSCLC.

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.

Utility and morphologic features of granulomas on rapid on-site evaluation of endobronchial ultrasonography-guided fine-needle aspiration

INTRODUCTION

Endobronchial ultrasonography (EBUS)-guided fine-needle aspiration (FNA) is increasingly used to sample central lung lesions and mediastinal lymphadenopathy. We investigate the utility of EBUS-guided FNA and concomitant rapid on-site evaluation (ROSE) to diagnose granulomas, the morphologic characteristics of granulomas on ROSE, and how the diagnosis of granulomas changed the clinical impression.

MATERIALS AND METHODS

All pathologic reports and associated clinical records of patients who had EBUS-guided FNA of the lungs or mediastinal lymph nodes that yielded granulomas were reviewed with at least a 1-year follow-up after EBUS-guided FNA. All ROSE slides were rereviewed to evaluate granulomas for quantity, necrosis, and cohesion.

RESULTS

Over a 3-year period, 882 EBUS-guided FNAs were performed. One hundred and twelve patients (49% male, average age 50.8 years, range 16-83) had 161 EBUS-guided FNAs that yielded granulomas (18%). The etiologies of the granulomas were as follows: sarcoidosis (54%), infection (12%), malignancy (5%), inflammatory bowel disease-related lymphadenopathy (1%), and no specific clinical etiology (28%). Of the patients with EBUS-guided FNAs, 98 had ROSE performed (87.5%) and granulomas were seen in 70 of these patients (71%). Granulomas associated with sarcoidosis were mostly well-formed and non-necrotizing (90%). The results of the EBUS-guided FNA changed or redefined the clinical diagnosis in 79 patients (71%).

CONCLUSIONS

EBUS-guided FNA with concurrent ROSE is a useful technique for the diagnosis of granulomas. The quality and quantity of granulomas detected during ROSE may suggest an etiology and help direct ancillary testing.

The cryo-needle: a new tool for histological biopsies. A feasibility study

PURPOSE

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a standard procedure for intrathoracic lymph node biopsies. The newly developed cryo-needle operates in a similar way to the EBUS-TBNA but is able to obtain specimens for histological evaluation. The purpose of this animal study was to evaluate the feasibility, effect, and safety of the cryo-needle biopsies.

METHODS

Four EBUS-guided cryo-needle biopsies were obtained from a mediastinal lymph node of a healthy pig. In an open surgery approach, cryo-needle biopsies using activation times of 1, 2, and 3 s (A1/A2/A3) and needle biopsies using a 21-gauge EBUS-TBNA needle were obtained from mesenteric lymph nodes. Cryo-needle biopsies A2 were performed with (A2+) and without (A2-) an oversheath. The size, weight, percentage of lymphatic tissue and artefact-free area of each cryobiopsy were evaluated. Smears were made with the TBNA-needle aspirates to determine the number of lymphocytes per high-power field (HPF). The bleeding duration was measured.

RESULTS

We successfully obtained EBUS-guided cryo-needle biopsies. The area and weight of the biopsies A3 and A2+ were significantly larger compared with A1 (1.7 ± 0.8 and 1.4 ± 0.3 vs. 0.9 ± 0.4 mm(2); 5.2 ± 2.4 and 3.4 ± 1.8 vs. 1.5 ± 0.7 mg). The percentage of lymphatic tissue of the cryobiopsies was 90 ± 25 and 98 % of samples were artefact-free. The number of lymphocytes/HPF of TBNA-needle smears was 128 ± 54.3. There was no difference in bleeding duration between the techniques.

CONCLUSIONS

The cryo-needle yields large histological specimens of high quality.

Microfluidic sample preparation for diagnostic cytopathology

The cellular components of body fluids are routinely analyzed to identify disease and treatment approaches. While significant focus has been placed on developing cell analysis technologies, tools to automate the preparation of cellular specimens have been more limited, especially for body fluids beyond blood. Preparation steps include separating, concentrating, and exposing cells to reagents. Sample preparation continues to be routinely performed off-chip by technicians, preventing cell-based point-of-care diagnostics, increasing the cost of tests, and reducing the consistency of the final analysis following multiple manually-performed steps. Here, we review the assortment of biofluids for which suspended cells are analyzed, along with their characteristics and diagnostic value. We present an overview of the conventional sample preparation processes for cytological diagnosis. We finally discuss the challenges and opportunities in developing microfluidic devices for the purpose of automating or miniaturizing these processes, with particular emphases on preparing large or small volume samples, working with samples of high cellularity, automating multi-step processes, and obtaining high purity subpopulations of cells. We hope to convey the importance of and help identify new research directions addressing the vast biological and clinical applications in preparing and analyzing the array of available biological fluids. Successfully addressing the challenges described in this review can lead to inexpensive systems to improve diagnostic accuracy while simultaneously reducing overall systemic healthcare costs.

Investigation of the flexibility of bronchoscopes

Objective

For transbronchial biopsy of peripheral pulmonary lesions manouevering the biopsy instrument into acutely angulated subsegmental ostia is frequently problematic. The aim of the present study was to compare the stiffness of various biopsy instruments with regard to their use in the clinical setting.

Methods

The maximal anterograde and retrograde bending angles, were measured for various bronchoscopes and biopsy instruments. Measurement was made with the distal tip of the biopsy instrument either flush with the distal end of the bronchoscope, or extending 1.5 cm beyond it. The following scopes and biopsy instruments were investigated: 1. the 6.2 mm outside diameter (OD) bronchoscope, with the 2.4 mm OD forceps, 0.7 mm needle, 2.3 mm catheter, and the 1.9 mm cryoprobe. 2. the 5.1 mm OD bronchoscope, with the 1.8 mm forceps, 0.7 mm needle, and the 1.8 mm catheter. 3. the 3.7 mm bronchoscope, with the 1.0 mm forceps and the 0.8 mm forceps.

Results

Maximum angulation was greater by 35.4° with the needle extended, vis-à-vis the needle "flush". Both needle and catheter were associated with a greater angulation of up to 20.5° in comparison with the forceps. With an instrument in the working channel the largest anterograde angles were measured for the 5.1 mm bronchoscope, and the largest retrograde angles for the 6.2 mm bronchoscope.

Conclusion

When selecting the optimal instrument for transbronchial biopsy specimen collection, account must be taken of the fact that the degree of angulation will depend on the type and diameter of the instrument employed.

Acquisition and processing of endobronchial ultrasound-guided transbronchial needle aspiration specimens in the era of targeted lung cancer chemotherapy

Recent advances in therapy for non-small cell lung carcinoma have shown that a personalized approach to treatment has the potential to significantly reduce lung cancer mortality. Concurrently, endoscopic ultrasound transbronchial needle aspiration has emerged as an accurate and sensitive tool for the diagnosis and staging of this disease. As knowledge of the molecular mechanisms that drive lung cancer progression increases, the amount of information that must be derived from a tumor specimen will also increase. Recent clinical studies have demonstrated that small specimens acquired by endoscopic ultrasound transbronchial needle aspiration are sufficient for molecular testing if specimen acquisition and processing are done with these needs in mind. Optimum use of this procedure requires a coordinated effort between the bronchoscopist and the cytopathologist to collect and triage specimens for diagnostic testing. When feasible, rapid onsite evaluation should be performed to assess the specimen for both diagnostic quality and quantity and to allocate the specimen for cell-block and possible immunohistochemistry and molecular studies. It is necessary for pulmonologists and bronchoscopists to understand the rationale for histologic and molecular testing of lung cancer diagnostic specimens and to ensure that specimens are acquired and processed in a fashion that provides information from small cytologic specimens that is sufficient to guide treatment in this era of targeted therapy.

Endoscopic ultrasound guided transbronchial fine needle aspiration: a French Department of Pathology's 4-year experience

Background

Endobronchial ultrasound (EBUS) guided transbronchial needle aspiration (TBNA) is an accurate outpatient procedure used to explore mediastinal lymph nodes for lung cancer staging and unexplained mediastinal masses.

Aims and methods

A retrospective study was conducted over four years on EBUS-TBNA sampled lymph nodes investigated for the staging of lung cancer or unexplained mediastinal lymphadenopathies, first using the conventional method (CM) and then a liquid based cytology (LBC).

Results

Of the 628 specimens (355 patients) collected, the overall rate of adequacy was 88% and the diagnosis of malignancy was achieved in 43% of cases. The inadequate rate was 6% with LBC and 21% with CM. A paraffin cytoblock was available in 80% with LBC and 62% with CM. Of the 628 aspirates, 270 (43%) were categorised as negative for malignancy including 26 cases consistent with sarcoidosis, 272 (43%) as malignant, 9 (1.4%) as suspicious for non-small-cell carcinoma and 77 as inadequate samples (12%). Of the 272 cases diagnosed as malignant, 87 (32%) were classified as non-small-cell carcinoma, 106 (39%) as adenocarcinoma, 48 (18%) as squamous cell carcinoma and 20 (7%) as small cell carcinoma. Five lymphomas, four metastatic melanomas and two carcinoids were also diagnosed.

Conclusions

EBUS-TBNA is a reliable method for the staging of lung cancer and for unexplained mediastinal mass exploration. The LBC has a lower rate of inadequate samples, a better yield of cytoblock for immunohistochemistry and a dramatically reduced time requirement for interpretation as compared to CM.

Endobronchial ultrasound-guided transbronchial needle aspiration biopsy is useful evaluating mediastinal lymphadenopathy in a cancer center

Background:

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) biopsy is used to stage mediastinal lymph nodes in cancer patients to optimize treatment strategies. In this retrospective study, the authors determined the utility of EBUS-TBNA biopsy in the evaluation of mediastinal lymphadenopathy at a high-volume cancer center.

Materials and Methods:

The pathology database was searched for all patients who had undergone EBUS-TBNA biopsy of mediastinal lymph nodes over a one-year period. Cytologic diagnoses were correlated with clinical histories, subsequent resection, and clinical follow-up data.

Results:

Of 928 lymph node samples, 226 (24%) were diagnosed as malignant, 4 (0.4%) were suspicious for malignancy, 9 (1%) were atypical, 640 (69%) were benign, and 47 (5%) were insufficient for evaluation. In 89 (9.6%) cases, the patients had surgical resection. There was one false positive, in which the primary tumor contained infiltrating lymphocytes, had been sampled. There were five false-negative cases, which resulted from sampling errors, including two with micrometastases. The sensitivity, specificity, and positive and negative predictive value rates for EBUS-TBNA biopsy in the evaluation of mediastinal lymph nodes were 68.7% and 98.6% and 91.6% and 93.5%, respectively on a per lymph node basis. The overall clinical sensitivity, specificity, and positive and negative predictive value rates after one year clinical/radiological and histologic follow-up were 97%, 99.3%, 96.7% and 99.4%, respectively.

Conclusions:

EBUS-TBNA biopsy is a sensitive and specific method for evaluating mediastinal lymphadenopathy in patients with lung and other primary tumors.