exfoliative respiratory cytology (part 1 of 2)
DESCRIPTION
An introduction to respiratory cytology. Includes info on benign and malignant cytology findings. Discussion on different specimen types including sputum, bronchoalveolar lavage, and brushings.TRANSCRIPT
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A short primer on
Exfoliative respiratory cytology
September 2007
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Acquisition of specimens
• Sputum
• BAL / Bronchial wash
• Bronchial brush
• Pleural fluid
• Needle biopsy– Transbronchial– Transesophogeal– Transaortic
• Transthoracic FNA
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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)
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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
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Bronchoalveolar lavage
• Useful for– Peripheral lesions– Severe diffuse disease– Evidence of inoperability– Diagnosis of opportunisitc infections– Interstitial lung disease– Evaluation of transplant rejection
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Evaluation• Adequacy: bronchial cells,
abundant macrophages
• Keep your eyes peeled for:– Fungus– Pneumocystis– Viral inclusions– Hemosiderin-laden
macrophages– Atypical or malignant cells
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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
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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
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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
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Nonspecific findings
• Reserve cells– Small round lymphocyte like– Central, hyperchromatic nuclei
• Bronchial irritation cells• Reactive atypia• Multinucleation• Regenerative/Reparative• Ciliocytophthoria (ciliated tufts)
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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)
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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.
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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.
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Case of suspicious lesion
• Biopsy versus resection• Excisional biopsy is more sensitive• No role for TTNA in early stage disease or
in surgical candidates
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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.