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

Clinical values of different specimen preparation methods for the diagnosis of lung cancer by EBUS-TBNA

BACKGROUND AND OBJECTIVE

EBUS-TBNA has emerged as an important minimally invasive procedure for the diagnosis and staging of lung cancer. Our objective was to evaluate the effect of different specimen preparation from aspirates on the diagnosis of lung cancer.

METHODS

181 consecutive patients with known or suspected lung cancer accompanied by hilar / mediastinal lymphadenopathy underwent EBUS-TBNA from January 2019 to December 2022. Specimens obtained by EBUS-TBNA were processed by three methods: Traditional smear cytology of aspirates (TSC), liquid-based cytology of aspirates (LBC) and histopathology of core biopsies.

RESULTS

EBUS-TBNA was performed in 181 patients on 213 lymph nodes, the total positive rate of the combination of three specimen preparation methods was 80.7%. The diagnostic positive rate of histopathology was 72.3%, TSC was 68.1%, and LBC was 65.3%, no significant differences was observed (p = 0.29); however, statistically significant difference was noted between the combination of three preparation methods and any single specimen preparation methods (p = 0.002). The diagnostic sensitivity of histopathology combined with TSC and histopathology combined with LBC were 96.5 and 94.8%, the specificity was 95.0% and 97.5%, the PPV was 98.8% and 99.4%, the NPV was 86.4% and 81.2%, the diagnostic accuracy was 96.2% and 95.3%, respectively; The sensitivity and accuracy of above methods were higher than that of single specimen preparation, but lower than that of combination of three preparation methods.

CONCLUSION

When EBUS-TBNA is used for the diagnosis and staging of lung cancer, histopathology combined with TSC can achieve enough diagnostic efficiency and better cost-effectiveness.

Endobronchial ultrasound-guided transbronchial needle aspiration for the diagnosis of pulmonary sarcoidosis: A 9-year experience at a single center

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is valuable for diagnosing pulmonary sarcoidosis. We aimed to evaluate the diagnostic yield of EBUS-TBNA and cytology in sarcoidosis during the first 9 years at our institution.

METHODS

Patients who underwent EBUS-TBNA for suspected sarcoidosis between January 2011 and November 2019 were identified retrospectively. EBUS-TBNA was performed with rapid on-site cytological evaluation of the samples. The final diagnosis was based on the pathology and/or cytology results, radiologic features, and clinical follow-up findings. The yield rate was analyzed annually.

RESULTS

Eighty patients underwent 83 EBUS-TBNA procedures for suspected sarcoidosis. In total, 136 lymph nodes were sampled. The mean number of lymph node stations sampled was 2.0 ± 0.6; the mean number of needle passes per lymph node was 3.5 ± 0.8. Sixty-five patients were diagnosed with sarcoidosis, with a total of 68 procedures. Nonnecrotizing granulomatous inflammation was detected in the EBUS-TBNA samples from 49/68 procedures (yield rate: 72.1%). Of 19 patients with sarcoidosis who did not obtain a pathological diagnosis with EBUS-TBNA, epithelioid cells and/or multinuclear giant cells suggestive of granulomatous inflammation were detected in five. The sensitivity, specificity, positive predictive value, and negative predictive value (NPV) for pathological diagnosis of sarcoidosis using EBUS-TBNA were 72.1%, 100%, 100%, and 24.0%, respectively. On using cytology, the sensitivity and NPV increased to 79.4% and 26.3%, respectively. The yield rate did not increase until 2016.

CONCLUSION

EBUS-TBNA is useful for diagnosing sarcoidosis. Cytology resulted in an additional yield rate of 7.3%, which improved as the number of cases increased.

Liquid-based rapid onsite evaluation of endobronchial ultrasound cytologies

INTRODUCTION

Rapid onsite evaluation (ROSE) generally uses smears made at the site of the procedure ("smear-based ROSE"). It requires considerable time, generally 2 individuals, technical expertise, and it can be difficult to estimate material available for ancillary studies. We developed an alternative ROSE using liquid-based cytology ThinPrep with hematoxylin and eosin (H&E) stain ("liquid-based ROSE") and assessed its advantages.

MATERIALS AND METHODS

Clinicians rinse the sample(s) into CytoRich Red and send to Pathology. A defined proportion of the needle rinse is removed for a ThinPrep stained with a rapid H&E. Adequacy and diagnosis were compared to final outcome. Total time was recorded.

RESULTS

Among 52 liquid-based ROSE readings, 28 (53.8%) were interpreted as "adequate" with final as adequate; 17 (32.7%) were interpreted as "inadequate" with final as inadequate; 7 (13.5%) were interpreted as "inadequate" with final as adequate. Of 23 readings provided with onsite diagnosis, 15 (65.2%) were interpreted as definitive positive or negative diagnoses; 6 (26%) were interpreted as nondiagnostic; and 2 (8.7%) were interpreted as atypical. All definitive diagnoses were concordant with final diagnoses. The time for liquid ROSE performance ranges from 6 to 22 minutes (mean: 13 minutes) and required only 1 individual.

CONCLUSIONS

Liquid-based ROSE allows accurate adequacy determination and diagnosis, takes about 15 minutes of cytologist time, and can be performed by just 1 person. The technique produces well-preserved and stained slides, it may allow a better estimation of the total amount of material in the specimen vial and may provide a better platform for telecytology.

Diagnostic value of liquid-based cytology test in intrathoracic lymph nodes and lung lesions sampled by endobronchial ultrasonography-transbronchial needle aspiration

BACKGROUNDS

Liquid-based cytology (LBC) has begun to be used in non-gynecological samples such as endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). This study aims to investigate the diagnostic value of LBC in intrathoracic lymph nodes and lung lesions sampled with EBUS-TBNA.

METHODS

In total, 174 cases that underwent EBUS-TBNA between July 2020 and February 2021 were included (75 and 99 cases were prepared using conventional and LBC methods, respectively). The two groups were compared in terms of diagnostic categories, number of slides, cell blocks, slides per location, locations sampled, immunohistochemical studies, sensitivity, specificity, and diagnostic accuracy.

RESULTS

The percentages of malignant, suspicious for malignancy, benign, and non-diagnostic (ND) cases were 51.8%, 1.1%, 39.6%, and 7.5%, respectively. The LBC and conventional group (CG) had similar rates in the diagnostic categories, except for ND (3.0% and 13.3%, respectively). The sensitivity of LBC and CG were 90.4% and 85.7%, respectively. There were no differences in the specificity and diagnostic accuracy between groups. There was a statistically significant difference between groups in terms of the number of slides, number of slides per location, number of cell blocks, and locations sampled (p < .001, p < .001, p < .05, p < .05).

CONCLUSION

The LBC technique can be used for samples taken with EBUS-TBNA. Rapid fixation and the absence of artificial problems greatly reduce the rate of ND samples in LBC slides. Other important advantages are a lower number of slides to examine and a greater number of cell blocks.

Evaluation of DNA and RNA quality from archival formalin-fixed paraffin-embedded tissue for next-generation sequencing - Retrospective study in Japanese single institution

Genetic analysis on formalin-fixed paraffin-embedded (FFPE) tissue specimens has become a mainstream method, from conventional direct sequencing to comprehensive analysis using next-generation sequencing (NGS). In this study, we evaluated the quality of DNA and RNA extracted from FFPE sections, derived from surgical specimens of different tumor types. Electrophoresis was performed using a 4200 TapeStation to evaluate DNA and RNA fragmentation. DNA Ct values were higher and significantly increased over a period of 4 years compared with those from cell lines or frozen tissues. The RNA integrity number equivalent (RIN) ranged from 1 to 4.1 and DV200 ranged from 7.3 to 81%. Twelve of the 108 cases were analyzed by NGS using the AmpliSeq Cancer HotSpot Panel v2 on a Miniseq system. A sufficient number of reads and coverage were obtained in all cases. Our results revealed that NGS analysis was sufficient for FFPE-derived DNA within 4 years of preservation. Conversely, approximately 20% of the RNA derived from FFPE within 4 years from the collection could be inappropriate for gene analysis based on RIN and DV200. It was suggested that FFPE would be adequate for genetic analysis, although it is desirable to store frozen specimens for the tumor tissues to be subjected to genetic analysis.

Values of different specimen preparation methods for the diagnosis of lung cancer by endobronchial ultrasound guided transbronchial needle aspiration

Background

Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) has been become an important procedure for the diagnosis and staging of lung cancer. Our research identified the effects of different pathological preparation on the diagnosis of lung cancer for specimens obtained by biopsy.

Methods

Patients were clinically considered if lung cancer was accompanied by mediastinal or hilar lymph node enlargement between March 2014 and November 2017. Specimens obtained by EBUS-TBNA were treated by three methods: traditional smear cytology, liquid-based cytology (LBC) and histopathology.

Results

Of a total of 154 puncture sites from 153 patients, the total positive rate of combination for the three pathological treatment types (histopathology, direct traditional smear, and LBC) was 77.3%. The diagnostic positive rate for histopathology was 68.6%, direct traditional smear was 65.6%, and LBC was 60.4%; there was no significant differences among the three single pathological treatment types (P = 0.29), but there was a statistically significant difference between the combination of three treatments and any single pathological treatment type (P = 0.01). The diagnostic sensitivities of histopathology combined with traditional smear and histopathology combined LBC were 94.4 and 92.8%, respectively, the specificities and PPVs were both 100%, and the diagnostic accuracies were 95.5 and 94.2%, respectively; the sensitivities, specificities and diagnostic accuracies above were all higher than those of single specimen treatment and lower than those of the three combined.

Conclusion

When EBUS-TBNA is used for the diagnosis and staging of lung cancer, the use of histopathological sections combined with direct cytological smear should be sufficient and is the most economical choice.

Processing and Reporting of Cytology Specimens from Mediastinal Lymph Nodes Collected using Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: A State-of-the-Art Review

Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) is presently the preferred modality for sampling mediastinal lymph nodes. There is an unmet need for standardization of processing and reporting of cytology specimens obtained by EBUS-TBNA. The manuscript is a state-of-the-art review on the technical aspects of processing and reporting of EBUS-TBNA specimens. A literature search was conducted using the PubMed database, and the available evidence was discussed among the authors. The evidence suggests that at least one air-dried and one alcohol-fixed slide should be prepared from each lymph node pass. The remaining material should be utilized for microbiological analysis (in saline) and cell block preparation (10% formalin or other solutions). Wherever available, rapid-onsite evaluation should be performed to assess the adequacy of the sample and guide the need for additional material. The lymph node aspirate should also be collected in Roswell Park Memorial Institute solution in cases where lymphoma is under consideration. The use of liquid-based cytology provides good quality specimens that are free from blood and air-drying artifacts and can be used wherever available. Sample adequacy and the diagnostic category should be furnished separately in the cytology report.

[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.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: Techniques and Challenges

Intrathoracic lymphadenopathy is a common problem encountered in clinical practice and is caused by a wide variety of diseases. Traditionally, the mediastinal lymph nodes were sampled using conventional transbronchial needle aspiration (TBNA), or surgical methods such as mediastinoscopy, and thoracotomy (open or video-assisted thoracoscopy). However, surgical modalities including mediastinoscopy are invasive, expensive, and not universally available. Moreover, they are associated with considerable morbidity and mortality. Conventional TBNA although minimally invasive has a low diagnostic yield. In the last decade, endobronchial ultrasound-guided TBNA (EBUS-TBNA) has emerged as the diagnostic procedure of choice in evaluating undiagnosed intrathoracic lymphadenopathy. EBUS-TBNA is also currently the preferred modality in the mediastinal staging of lung cancer. The procedure is minimally invasive, safe, and can be performed as a day-care procedure. In the era of personalized medicine in lung cancer, optimizing the procedure, sample collection, and processing are crucial, as more tissue is required for performing a wide array of molecular tests. Despite its widespread use and acceptance, the diagnostic sensitivity of EBUS-TBNA is still low. To maximize the yield, cytologists and physicians should be aware of the technical details of the procedure. Herein, we discuss the technique of performing EBUS-TBNA, its indications, contraindications, and the processing of the samples at our bronchoscopy suite. We also highlight the challenges faced by the cytologists and clinicians while processing EBUS aspirates.

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.

Recent advances in endobronchial ultrasound-guided transbronchial needle aspiration

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive modality for sampling of mediastinal and hilar lymph nodes as well as pulmonary lesions adjacent to the airway. Guidelines for staging of lung cancer suggest that EBUS-TBNA should be considered the best first test of nodal staging for radiologically abnormal lymph nodes that are accessible by this approach. The application of EBUS-TBNA in pulmonary medicine and thoracic oncology is expanding with its role in the diagnosis of sarcoidosis, lymphoma, and tuberculosis. Especially for patients with early-stage sarcoidosis with adenopathy and minimal changes in the lung parenchyma, EBUS-TBNA has a significantly higher diagnostic yield compared to the conventional bronchoscopic modalities. Multidirectional analysis of samples obtained by EBUS-TBNA has allowed assessment of lymphoma and molecular analysis in lung cancer. Histological evaluation with immunohistochemistry, flow cytometry, fluorescence in situ hybridization, and chromosome analysis can be performed if good-quality samples can be obtained. Molecular analyses such as identification of epidermal growth factor receptor (EGFR) mutation and anaplastic lymphoma kinase (ALK) fusion gene detection now are being performed routinely with good sampling. One of the advantages of EBUS-TBNA is the ability to perform repeat procedures in a minimally invasive way. Restaging of the mediastinum after induction therapy can be done safely and with ease compared to repeat surgical procedures. With improvement in molecular analysis technology, comprehensive gene expression analysis will become important in the management of patients with lung cancer. Further advances in EBUS technology and needles for tissue sampling likely will help bronchoscopists to acquire ideal tissue.

Combination of virtual bronchoscopic navigation with conventional transbronchial needle aspiration in the diagnosis of peribronchial pulmonary lesions located in the middle third of the lungs

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is frequently applied to the diagnosis of central airway lesions, and endobronchial ultrasound with a guide sheath (EBUS-GS) is mainly used for the diagnosis of peripheral pulmonary lesions. However, there remains an unmet need to improve the diagnostic yields for peribronchial pulmonary lesions located along the secondary/tertiary and fourth/fifth bronchi (the "middle third zone" of the lungs), which neither EBUS-TBNA nor EBUS-GS can easily approach.

METHODS

A combination of virtual bronchoscopic navigation (VBN) with conventional TBNA was utilized for the cytological diagnosis of 15 patients with small pulmonary lesions (less than 20mm in diameter) in the middle third zone between March 2012 and January 2015 in our respiratory institute. The lesions were traced using the VBN system, and then the VBN was operated and guided by the vision of actual bronchoscopy. The TBNA site was determined by VBN, and the specimens were obtained using conventional TBNA under X-ray fluoroscopy. The diagnosis was made based on the cytological findings of the specimens.

RESULTS

Adequate specimens were obtained in 12 (80.0%) of the cases through the novel technique of combining TBNA with VBN in bronchoscopic examinations. Seven out of the ten malignant cases (70.0%) were definitely diagnosed by this procedure. No adverse effects were experienced, except for an acceptable amount of bleeding.

CONCLUSIONS

The combination of VBN with conventional TBNA was advantageous and safe for the cytological diagnosis of small peribronchial pulmonary lesions in the middle third zone of the lungs.