SELECTED DILEMMAS IN RESPIRATORY CYTOPATHOLOGY (2 … · SELECTED DILEMMAS IN RESPIRATORY...
Transcript of SELECTED DILEMMAS IN RESPIRATORY CYTOPATHOLOGY (2 … · SELECTED DILEMMAS IN RESPIRATORY...
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SELECTED DILEMMAS IN RESPIRATORY CYTOPATHOLOGY (2 CASES)
Dr. Mariamma Joseph Professor of Pathology Division Head – CytopathologyDepartment of Pathology and Laboratory Medicine LHSC and Western University
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Objectives
1) An Interesting EBUS FNA Lung Case – Unusual cytomorphology– How to optimize samples for molecular tests,
LHSC experience
2) A Challenging Effusion Case– Patterns and pitfalls in effusion cytology
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Case 1
• 60 F, 40 pack year smoker• Productive cough, un resolving pneumonia• CT: RUL mass (9x6x5cm)• Mediastinal adenopathy, adrenal & brain Met• Stage 1V disease
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Diagnostic ModalityEBUS FNA Biopsy, 4R lymph Node
Paratracheal
Olymbus bronchoscopeUS probe with transducerNeedle (22g)
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LHSC EBUS – FNA ServiceN=340 cases/yr
• Success of EBUS-FNAB service depends on the combined skill and competency of the pulmonologists, cytotechnologists and cytopathologists – Total health care team
Clinicians
PathologistsCyto P (5) and Molecular P
Cytotechs (8)
EBUS (5)
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Professor at Harvard Surgeon at Bringham H
CHECK LIST Manifesto: Dr. Atul Gawande
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ROSE Form
DM
9:009: 35
11
X 3RH
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FNAB + Needle Rinses
Place tissue cores & needle rinses in
Formalin
ROSE: 1 or 2 Passes
No ROSE: remaining Passes x 2-3
Pap stainDiff Q
uik
FLOW CHART for EBUS at LHSCFor suspected lymphoma, place a sample in Flow medium
Formalin Cell BlockFCBC, FCBP (Histogel)
Thin Prep
Cytology Lab
CytoLyt Cell Block - CCB
ROSE needle rinses in CytoLyt
Cytology Lab
FormalinCytoLyt
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Strategies to Optimize EBUS Samples for Molecular Tests
ThinPrep Diffquik Pap FCBC FCBP
Save sample for molecular testing ROSE by cytotechs Formalin fixation – high quality CBs Do not trim sign for CB Semi quantitation of malignant cells Judicious use of immuno-markers for cell
typing (P40 and TTF-1) Aim: maximize sample for ALK,EGFR,
PD-L1…..
Ref: Arch Pathol Lab Med 2017;141:402-409
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Current Case: ROSE
ADEQUATE: Lesionalcells present Obtain more material (additional passes in formalin) Cell block FCM: NoMicrobiology: No
Diff Quik stain
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CytomorphologyEmperipolesis
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Cell Block: Emperipolesis
High cellularity >100 cells, PASD: NegativeImmuno:Positive: CK7 Negative: P40, &TTF-1 Molecular:Negative: EGFR and ALK
PD-L1 – not requested
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DiagnosisNon-small cell carcinoma.
Morphological features favour Giant Cell Carcinoma.
Comment: Definite diagnosis of this subtype may only be made on the
resected specimen
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Giant Cell Carcinoma Lung
• Rare subtype of non small cell carcinoma – <1% of all lung cancers, > male (5:1)
• Aggressive, present with advanced disease• WHO: Pleomorphic (spindle/giant cell) ca• Cytomorphology: emperipolesis
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EmperipolesisPhysiological: • Megakaryocytes: Increased expression of P- selectin (a
cell adhesion molecule) on the surface of megakaryocytes promote increased neutrophil-megakaryocyte interaction
Pathological:• Rosai-Dorfman disease • Carcinoma: Giant cell carcinoma
• Oral squamous cell ca• Hemato-lymphoid disorders• Neuroblastoma, rhabdomyosarcoma
Journal of Clinical and Diagnostic Research 2014 Vol8 (12): ZMO1
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Munnar Resort, Kerala
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Case 2
• 74-year-old male smoker • (R) pleural effusion • Diagnostic sample: Pleural fluid cytology
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Cell Block
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Adenocarcinoma4 Cytologic Patterns
• Classic Dual Cell (two-cell) Pattern• Cell Balls/Proliferation Spheres• Papillary Pattern • Single cell Pattern (rare)
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Pattern 1: Dual Cell (Two Cell) Pattern
Clusters of adenocarcinoma cells, severe nuclear atypiaReactive mesothelial cells in background
Proved to be Lung primary
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Pattern1: Dual Cell Pattern
Clusters of adenocarcinoma cells, moderate nuclear atypia
Proved to be Lung primary
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Tightly cohesive uniform cancer cells with smooth community border
Pattern 2: Cell Balls/Proliferation Spheres
Proved to be Breast primary
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Pattern 2: Cell Balls and Large Elongated Proliferation Cylinders
Proved to be Breast primary
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Pattern 3: Papillary Pattern (Peritoneal Fluid, Female)
Primary Ovary
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Pattern 4: Single Cell Pattern
Proved to be Lung primary
Marked nuclear atypia
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Pattern 4: Single Cell Pattern
Proved to be Colon primary
Moderate nuclear atypia
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Pattern 4: Single Cell Pattern
Breast primary
Minimal atypia, resemble reactive mesothelial cells
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Single Cell Adenoca Atypical Mesothelial cells
Abundant single cells, clean background Monomorphic populationNuclear atypia variable, can be mild DDx: Lymphoma, melanoma, Sarcoma
Inflammatory backgroundDense/ two toned cytoplasmBlebs, microvilli (lacy skirt), windowsNuclear atypia mild, nucleoli
Immuno Essential for Dx
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Adenoca vs Atypical Mesothelial Cells
• Adenoca markersMOC 31 BER EP4TTF-1CEA (polyclonal)BRST-3 (B72.3)
• Mesothelial cell markers CalretininCK 5/6 WT1 (not commonly used in cytology)
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MOC31 CEA
Ber EP4
Single cell malignant effusion
Breast Primary
B72.3
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Current Case
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MOC 31 BER EP4
TTF-1 Calretinin
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Diagnosis Pleural fluid: Adenocarcinoma consistent with lung primary
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Take Home Message • Effusion fluid is a diagnostic sample,
precise diagnosis is feasible • Be aware of single cell malignant effusion• Utilize CB for ancillary studies• Molecular testing is feasible on pleural
fluid (requires high cellularity and formalin fixation)
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Thank you