. Step 17 of 40
Clinical Stem 2
A patient with pulmonary nodules 1 year after curative intent resection of primary lung adenocarcinoma

Answer C
Bronchoscopic lavage and brushing specimens from peripheral lung lesions provide a cytomorphologic diagnosis of malignancy in approximately 60% and 45% of cases, respectively. The yield is less for lesions less than 3 cm in diameter. Brushings are the only source of diagnosis in approximately 5% of cases. BAL fluid processing has been standardized. A combination of techniques is indicated to increase diagnostic yield.

Accuracy of definitive cytomorphologic diagnosis is 96%, although in studies, brushings and lavage specimens are typically under-represented compared with fine needle aspirations or pleural fluid. Overall accuracy of cytologic tumor subtyping in concordance with histology is 93%.

There are concerns that low cellularity in exfoliative cytology samples such as sputum, bronchial washes, brushings, and lavage may not provide adequate material for molecular testing, but any cytology specimen with cellular material in suspension can be processed and saved as a paraffin-embedded cell pellet, also known as a cell block.

Cytologic specimens from fine needle aspiration, pleural fluid, bronchial washing, brushing and BAL are suitable for EGFR and KRAS sequencing. In the case of EFGR, sensitivity for mutation detection is comparable to that of surgical specimens.

Considering the rapidly evolving role and growing number of molecular markers relevant to lung cancer patient management, the adequacy of cytology samples should be determined on an individual basis by a cytopathologist. Similar to surgical specimens, cell blocks are used for immunohistochemistry or molecular testing processing.

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References:
  1. Mazzone P, Jain P, Arroliga AC, Matthay RA. Bronchoscopy and needle biopsy techniques for diagnosis and staging of lung cancer. Clin Chest Med. 2002; 23: 137-58.
  2. Rekhtman N, Brandt SM, Sigel CS, et al. Suitability of thoracic cytology for new therapeutic paradigms in non-small cell lung carcinoma: high accuracy of tumor subtyping and feasibility of EGFR and KRAS molecular testing. J Thorac Oncol. 2011; 6: 451-8.
  3. Smouse JH, Cibas ES, Janne PA, et al. EGFR mutations are detected comparably in cytologic and surgical pathology specimens of nonsmall cell lung cancer. Cancer. 2009;117:67-72.
  4. Billah S, Stewart J, Staerkel G, et al. EGFR and KRAS mutations in lung carcinoma: molecular testing by using cytology specimens. Cancer Cytopathol. 2011 Apr 25;119:111-7.
  5. Clinical guidelines and indications for bronchoalveolar lavage (BAL): report of the European Society of Pneumology Task Group on BAL. Eur Respir J 1990; 3: 937?76.
  6. van der Drift MA, van der Wilt GJ, Thunnissen FB, et al. A prospective study of the timing and cost-effectiveness of bronchial washing during bronchoscopy for pulmonary malignant tumors. Chest 2005;128:394?400.
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