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

Cues• Lymphocytes

– 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 Bronchial brush cells

• Ciliated columnar cells

• Terminal bar

• Nuclei

– Basal oriented

– Round to oval

– Nuclear membrane smooth

• Chromatin

– Can appear hyperchromatic and coarse

– Regularly distributed

Glandular 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

• Direct mediastinal invasion– Mass in or adjacent to

hilum in 78% of cases

• Paraneoplastic syndromes– SIADH

– Ectopic ACTH

– Lambert-Eaton syndrome

• Diagnostic method based on presumed stage

• Thoracentesis if pleural effusion

• FNA of metastatic site

Diagnosis by easiest means: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.