Feasibility and accuracy of rapid on-site evaluation of touch imprint cytology during transbronchial biopsy

Optimizing tissue stewardship in non-small cell lung cancer to support molecular characterization and treatment selection: statement from a working group of thoracic pathologists

Many patients with non-small cell lung cancer do not receive guideline-recommended, biomarker-directed therapy, despite the potential for improved clinical outcomes. Access to timely, accurate, and comprehensive molecular profiling, including targetable protein overexpression, is essential to allow fully informed treatment decisions to be taken. In turn, this requires optimal tissue management to protect and maximize the use of this precious finite resource. Here, a group of leading thoracic pathologists recommend factors to consider for optimal tissue management. Starting from when lung cancer is first suspected, keeping predictive biomarker testing in the front of the mind should drive the development of practices and procedures that conserve tissue appropriately to support molecular characterization and treatment selection.

Artificial intelligence in interventional pulmonology

PURPOSE OF REVIEW

In recent years, there has been remarkable progress in the field of artificial intelligence technology. Artificial intelligence applications have been extensively researched and actively implemented across various domains within healthcare. This study reviews the current state of artificial intelligence research in interventional pulmonology and engages in a discussion to comprehend its capabilities and implications.

RECENT FINDINGS

Deep learning, a subset of artificial intelligence, has found extensive applications in recent years, enabling highly accurate identification and labeling of bronchial segments solely from intraluminal bronchial images. Furthermore, research has explored the use of artificial intelligence for the analysis of endobronchial ultrasound images, achieving a high degree of accuracy in distinguishing between benign and malignant targets within ultrasound images. These advancements have become possible due to the increased computational power of modern systems and the utilization of vast datasets, facilitating detections and predictions with greater precision and speed.

SUMMARY

Artificial intelligence integration into interventional pulmonology has the potential to enhance diagnostic accuracy and patient safety, ultimately leading to improved patient outcomes. However, the clinical impacts of artificial intelligence enhanced procedures remain unassessed. Additional research is necessary to evaluate both the advantages and disadvantages of artificial intelligence in the field of interventional pulmonology.

Clinical Utility of Rapid On-Site Evaluation of Touch Imprint Cytology during Cryobiopsy for Peripheral Pulmonary Lesions

Simple Summary

With increasing interest in precision medicine for lung cancer, cryobiopsy is expected to improve the success rate not only for histological diagnosis, but also for next-generation sequencing. Rapid on-site evaluation (ROSE) is an immediate cytological evaluation performed during bronchoscopy. However, little is known about its clinical utility during cryobiopsy. We retrospectively reviewed the data of 63 consecutive patients who underwent cryobiopsy with ROSE of touch imprint cytology (ROSE-TIC) for solid peripheral pulmonary lesions. When the results of ROSE-TIC of each patient were compared directly with the histological findings of the corresponding specimen, the sensitivity, specificity, and positive and negative predictive values were 69.8%, 90.0%, 93.8%, and 58.1%, respectively. The concordance rate was 76.2%. Therefore, we believe that ROSE-TIC, due to its high specificity and positive predictive value, may be a potential tool in deciding whether cryobiopsy sampling could be finished during bronchoscopy.

Abstract

Cryobiopsy enables us to obtain larger specimens than conventional forceps biopsy despite the caution regarding complications. This study aimed to evaluate the clinical utility of rapid on-site evaluation of touch imprint cytology (ROSE-TIC) during cryobiopsy of peripheral pulmonary lesions (PPLs). We retrospectively reviewed the data of consecutive patients who underwent cryobiopsy for solid PPLs between June 2020 and December 2021. ROSE-TIC was performed on the first specimen obtained via cryobiopsy and assessed using Diff-Quik staining. The results of ROSE-TIC for each patient were compared with the histological findings of the first cryobiopsy specimen. Sixty-three patients were enrolled in this study. Overall, 57 (90.5%) lesions were ≤30 mm in size and 37 (58.7%) had positive bronchus signs. The radial endobronchial ultrasound findings were located within and adjacent to the lesion in 46.0% and 54.0% of the cases, respectively. The sensitivity, specificity, and positive and negative predictive values of the ROSE results for histological findings of the corresponding specimens were 69.8%, 90.0%, 93.8%, and 58.1%, respectively. The concordance rate was 76.2%. In conclusion, ROSE-TIC, due to its high specificity and positive predictive value, may be a potential tool in deciding whether cryobiopsy sampling could be finished during bronchoscopy.

Accuracy of definitive rapid onsite evaluation cytopathology diagnoses: Assessment of potentially critical diagnoses as a quality assurance measure

INTRODUCTION

Intraprocedural rapid onsite evaluation (ROSE) of cytology specimens enhances cytopathology practice. More recently, ROSE diagnoses, like frozen section (FS) diagnoses, have guided immediate clinical decisions. In this study, we evaluated the diagnostic accuracy of definitive ROSE diagnoses in our quality assurance system over a 52-month period.

MATERIALS AND METHODS

Cytopathology cases with ROSE from January 2017 to April 2021were retrieved from our laboratory information system. After excluding cases that were deferred or nondiagnostic/unsatisfactory, each definitive ROSE diagnosis (ie, negative for malignant cells or positive for malignant cells) was categorized as having agreement or disagreement with the final diagnosis. For comparison, concordance of FS diagnoses from the same time period were tabulated and compared to those of ROSE diagnoses by using χ² testing with P < 0.05 considered statistically significant.

RESULTS

Of the 1649 ROSE diagnoses, there were 15 disagreements (0.9%) with 1 final moderate interpretive disagreement (0.06%). By comparison, of the 17,469 FS diagnoses, there were 141 disagreements (0.8%) with 49 final moderate or major interpretive disagreements (0.3%). The remaining disagreements were minor. There were no statistically significant differences in the rates of final moderate and major interpretive disagreements.

CONCLUSIONS

The final interpretive disagreement rates for definitive ROSE and FS diagnoses were similar in this study. Given the expanding role of ROSE and its use for immediate clinical decisions in some cases, monitoring the accuracy of definitive diagnoses may serve as an initial quality assurance measure.

Diagnostic Efficiency and Safety of Rapid On-Site Evaluation Combined with CT-Guided Transthoracic Core Needle Biopsy in Suspected Lung Cancer Patients

Objective

The efficacy of rapid on‐site evaluation (ROSE) combined with computed tomography‐guided transthoracic core needle biopsy (CT‐guided TCNB) is rarely investigated. This study aimed to evaluate the diagnostic efficiency and safety of ROSE combined with CT‐guided TCNB for suspected lung cancer patients.

Materials and Methods

Clinical data from 285 patients who received CT‐guided TCNB for suspected lung cancer in Huashan Hospital from 2015 to 2018 were retrospectively analysed. Of these 163 patients underwent CT‐guided TCNB combined with ROSE (ROSE group), while the remaining 122 patients underwent without ROSE (non‐ROSE group). The smears from TCNB were quickly processed with Diff‐Quick staining and analysed by a skilled cytologist on‐site. The consistency of ROSE with the final clinicopathological diagnosis and the diagnostic efficiency and safety of ROSE combined with CT‐guided TCNB in suspected lung cancer patients were evaluated.

Results

ROSE was highly concordant with pathological diagnosis (κ = 0.791; P < 0.001), with an accuracy of 95.7%. Diagnostic accuracy was significantly higher in the ROSE compared with the non‐ROSE group (96.3% vs 86.1%; P = 0.002), with overall incidences of complications of 36.8% and 23.8%, respectively. Minor pneumothorax without drainage was slightly greater in the ROSE compared with the non‐ROSE group (14.1% vs 6.6%; P = 0.046). However, there was no significant difference in serious complications between the two groups.

Conclusion

ROSE was highly consistent with the final clinicopathological diagnosis for suspected lung cancer. ROSE further improved the diagnostic efficiency of CT‐guided TCNB with no increased incidence of serious complications.

The Value of Additional Conventional Transbronchial Biopsy in the Negative Results of Rapid On-site Evaluation During Endobronchial Ultrasound With Guide Sheath to Diagnose Small Peripheral Lung Cancer

Objective: The accuracy of rapid on-site evaluation (ROSE) during endobronchial ultrasonography with guide sheath (EBUS-GS) was reported to be approximately 90% for diagnosing small peripheral pulmonary lesions (PPLs). When ROSE during EBUS-GS for diagnosing small peripheral lung cancer is carried out and does not include malignant cells in a position whereby the probe was located within or adjacent to the lesion, the best technique for overcoming the lower diagnostic yield remains unknown. This study aimed to evaluate factors affecting positive results of ROSE during EBUS-GS in such a probe position. Moreover, when the results of ROSE were consistently negative, we evaluated the effectiveness of conventional transbronchial biopsy (TBB) in addition to EBUS-GS alone. Methods: We performed a retrospective analysis of consecutive patients who underwent EBUS-GS combined with ROSE for diagnosing small peripheral lung cancer (≤30 mm). We classified the results of ROSE into two groups based on the presence of malignant cells: the ROSE positive group (included malignant cells) and the ROSE negative group (did not include malignant cells). The significant predictors of positive ROSE results during EBUS-GS were analyzed using multivariate logistic regression analyses. Results: We identified 67 lesions (43 lesions in the ROSE positive group and 24 lesions in the ROSE negative group, respectively). Multivariate logistic analysis revealed that the significant factor affecting positive ROSE results was lesion size (>15 mm) (OR = 9.901). The diagnostic yield of additional conventional TBB to EBUS-GS was significantly higher than that of EBUS-GS alone (75.0% vs 33.3%, P = .041). Conclusion: The positive results of ROSE during EBUS-GS were significantly influenced by lesion size (>15 mm). When the results of ROSE during EBUS-GS were consistently negative in a position whereby the probe was located within or adjacent to the lesion, additional conventional TBB was effective to improve the diagnostic yield compared with EBUS-GS alone.

Testing EGFR with Idylla on Cytological Specimens of Lung Cancer: A Review

The current standard of care for advanced non-small-cell lung cancer is based on detecting actionable mutations that can benefit from targeted therapy. Comprehensive genetic tests can have long turn-around times, and because EGFR mutations are the most prevalent actionable mutation, a quick detection would enable a prompt initiation of targeted therapy. Furthermore, the scarcity of diagnostic material means that sometimes only cytologic material is available. The Idylla™ EGFR assay is a real-time PCR–based method able to detect 51 EGFR mutations in 2.5 h. Idylla is validated for use only on FFPE sections, but some researchers described their experiences with cytological material. We reviewed the relevant literature, finding four articles describing 471 cases and many types of cytological input material: smears, cell-block sections, suspensions, and extracted DNA. The sensitivity, specificity, and limit of detection appear comparable to those obtained with histological input material, with one exception: the usage of scraped stained smears as input may reduce the accuracy of the test. In conclusion, usage of cytological material as input to the Idylla EGFR test is possible. A workflow where common mutations are tested first and fast, leaving rarer mutations for subsequent comprehensive profiling, seems the most effective approach.

The role of rapid on site evaluation on touch imprint cytology and brushing during conventional bronchoscopy

BACKGROUND

The increase in immunohistochemical and molecular predictive tests in lung cancer requires new strategies for managing small samples taken during bronchoscopic procedures. The value of Rapid On Site Evaluation (ROSE) during conventional bronchoscopic procedures on endobronchial neoplasms in optimizing small biopsies and cytologlogical tissue specimens for diagnostic testing, and ancillary studies was evaluated.

METHOD

ROSE on touch imprint cytology (TIC) and brushing was performed on 690 consecutive cases of patients undergoing biopsies, using fiber optic bronchoscopy. Immunohistochemical assay for PD-L1, ALK, and ROS1 and molecular testing, via next generation technique for EGFR, KRAS, and BRAF, were performed.

RESULTS

The concordance between ROSE and final diagnoses was almost perfect for brushing (sensitivity: 0.84; specificity: 0.96), and less so for touch preparations (sensitivity: 0.77; specificity: 0.89). Immunohistochemical assay for PD-L1 was evaluated on 256 bioptic cases with only six unsuitable samples. Material available for immunohistochemistry for ALK was sufficient in 151 biopsies with no inadequate cases. ROS1 was evaluated in 132 biopsies, with only two unsuitable samples. Molecular analysis was performed on 128 biopsies, 29 TIC, and 17 brushing. Out of these, only ten were considered to be unsuitable.

CONCLUSIONS

ROSE is an effective procedure for monitoring the quality and quantity of material taken during conventional bronchoscopic procedures for evaluating the suitability of small samples that must undergo immunohistochemical and molecular assay.