Exfoliative Respiratory Cytology (part 1 Of 2)

A short primer on

Exfoliative respiratory cytology September 2007

Acquisition of specimens • • • • •

Sputum BAL / Bronchial wash Bronchial brush Pleural fluid Needle biopsy – Transbronchial – Transesophogeal – Transaortic

• Transthoracic FNA

Sputum • Accuracy – Patient is spontaneously producing sputum – Vigorous sampling (3-5 early morning specimens) – Preservation techniques – Location and size of tumor • Central (SCLC, SCC)

– Sensitivity: • Sens 0.66, Spec 0.99 (average 16 studies) • Prebronchoscopy – suspected Lung Ca: sens 0.10-0.74 (8 studies)

• Central sens 0.71, Peripheral sens 0.49 (17 studies)

Sputum adequacy • Numerous alveolar macrophages • Patients with abnormal sputum cytology should undergo bronchoscopy... • Cells of bronchial cytology are – – – – – –

Better preserved More numerous More cohesive Larger Lesions can be localized Cleaner background

Bronchoalveolar lavage • Useful for – – – – – –

Peripheral lesions Severe diffuse disease Evidence of inoperability Diagnosis of opportunisitc infections Interstitial lung disease Evaluation of transplant rejection

Evaluation • Adequacy: bronchial cells, abundant macrophages

• Keep your eyes peeled for: – Fungus – Pneumocystis – Viral inclusions – Hemosiderin-laden macrophages – Atypical or malignant cells

• Lymphocytes

Cues

– Sarcoid – Hypersensitivity pneumonia • Drug reaction

• Neutrophils / Macrophages – Idiopathic pulmonary fibrosis – Cytotoxic drug reaction – Langerhans histiocytosis

• Hemosiderin laden macrophages – Occult pulmonary hemorrhage (not acute phase) – Also associated with infection

Bronchial wash cells

Glandular cells

• Ciliated columnar cells • Terminal bar • Nuclei – Basal oriented – Round to oval – Nuclear membrane smooth • Chromatin – Can appear hyperchromatic and coarse – Regularly distributed

Bronchial brush cells

Also • Squamous cells – Similar to gyn pap – Mostly superficial

• Goblet cells – Basally oriented nucleus and mucus – Usually one for every 5-10 ciliated cells – Abundant, finely vacuolated cytoplasm filled with mucus – Abundant in asthma, bronchitis, bronchiectasis, and allergies

• Clara cells – Nonciliated bronchiolar cells

• Pneumocytes • Macrophages – – – – – –

Bean nuclei Salt and pepper chromatin Carbon histiocytes Siderophages Lipophages Muciphages

Nonspecific findings • Reserve cells – Small round lymphocyte like – Central, hyperchromatic nuclei

• • • • •

Bronchial irritation cells Reactive atypia Multinucleation Regenerative/Reparative Ciliocytophthoria (ciliated tufts)

Other findings • • • •

Ferruginous (asbestos) bodies Elastin fibers Charcot-Leyden crystals Alveolar proteinosis – Grossly opaque fluid, background of debris

• Corpora amylacea– Related to pulmonary edema

• Calcospherites and Psammoma bodies • Contaminants (talc, pollen, plant/food cells)

Diagnosis of lung cancer • Suspicion based on abnormal radiologic findings or local or systemic effects • Diagnosis depends on – Type (NSC vs SC) – Size and Location – Presence or absence of metastasis – Clinical status of patient

• Maximize sensitivity • Avoid multiple invasive or unnecessary procedures.

Small cell versus non-small cell • Massive lymphadenopathy • Diagnostic method based on presumed stage • Direct mediastinal invasion • Thoracentesis if pleural – Mass in or adjacent to effusion hilum in 78% of cases • Paraneoplastic syndromes • FNA of metastatic site – SIADH – Ectopic ACTH – Lambert-Eaton syndrome

Diagnosis by easiest means:

Sputum → thoracentesis → FNA of node or met → bronchoscopy with or without TBNA.

Case of suspicious lesion • Biopsy versus resection • Excisional biopsy is more sensitive • No role for TTNA in early stage disease or in surgical candidates

References: • Diagnosis of Lung Cancer: The Guidelines. M. Patricia Rivera, Frank Detterbeck and Atul C. Mehta. Chest 2003;123;129-136. DOI 10.1378/chest.123.1_suppl.129S. • The Art and Science of Cytopathology. Demay. Exfoliative respiratory cytology. • Uptodate. Basic principles and technique of bronchoalveolar lavage. • Bronchoscopy International: Art of Bronchoscopy, an Electronic On-Line Multimedia Slide Presentation. http://www.Bronchoscopy.org/Art of Bronchoscopy/htm. Published 2005 (Accessed 9/11/2007). • www.cytologystuff.com •

Thanks to www.openoffice.org for allowing me to complete my presentation when Powerpoint didn’t work.