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Diagnostic Efficacy of Transthoracic and Transbronchial Fine Needle Aspiration: A Single Institution Experience
Abstracts
S53
Conclusions: Including head and neck tissue samples into the automated extraction system avoids manual processes, and decreases the chance of error. It has the advantage of including these cases into the routine cervical sample HPV runs. This eliminates the need for small kit sizes and longer intervals between runs, keeping costs lower and improving TAT for head and neck samples. It also provides a comparable alternative to ISH testing for FFPE samples. Table 1 Roche Sensitivity Roche Specificity NPV PPV
1.00 0.91 1.00 0.91
ISH Sensitivity ISH Specificity NPV PPV
0.97 0.97 0.97 0.97
121 Comparing Automated with Manual HPV, ISH, AND P16 Immunohistochemistry in Assessing Oropharyngeal Carcinoma (OPC) Nazneen Fatima, MD, Cynthia Cohen, MD, Momin T. Siddiqui, MD Emory University, Atlanta, Georgia Introduction: HPV-positive tumors comprise a unique subset of head and neck squamous cell carcinomas (HNSCCs) that are different from HPVnegative tumors in respect to tumor differentiation, genetic changes, risk factors, risk stratification and prognosis. Detection of HPV status is now a standard practice in the pathologic evaluation of HNSCCs. Determining the integration status of HPV by in situ hybridization (ISH) is cost effective and routinely utilized in clinical practice. Strong correlations have been reported between diffuse nuclear and cytoplasmic p16 immunohistochemical staining (IHC) and HPV DNA detection by ISH. In this study, we compared the efficacy of automated HPV ISH utilizing the Enzo probe with manual HPV ISH utilizing the Dako probe, and P16 IHC in the evaluation of OPCs. Materials and Methods: A total of 55 OPC small surgical biopsies were evaluated with automated HPV ISH utilizing the Enzo probe, the manual HPV ISH with the Dako probe, and P16 IHC. HPV ISH was interpreted as positive if a minimum of one tumor cell showed punctate dot like nuclear positivity. P16 was interpreted as positive if 70% of tumor cells showed brown nuclear and cytoplasmic staining. 10 small surgical biopsies from lung squamous cell carcinoma were studied as negative controls. Results: Fifty of 55 cases (90%) were positive for automated HPV ISH; 39 of 55 cases (70%) with manual HPV ISH. Forty four of 55 (80%) cases were positive for P16 IHC. Conclusions: In comparing automated HPV ISH utilizing Enzo probe with manual HPV ISH utilizing the Dako probe, and P16 IHC, we have determined that automated HPV ISH plays a more significant role in determining the HPV status in surgical biopsies as compared to the other two techniques. P16 staining is easier to recognize and evaluate on tumor cells in contrast to punctate dot like positivity seen in HPV ISH which may be very focal and requires careful evaluation at a higher magnification.
LUNG AND MEDIASTINUM 122 Diagnostic Efficacy of Transthoracic and Transbronchial Fine Needle Aspiration: A Single Institution Experience Congli Wang, MD, Varsha Manucha, MD, Michael J. Carrozza, BS, Yajue Huang, MD, PhD Temple University Hospital, Philadelphia, Pennsylvania Introduction: CT-guided transthoracic fine needle aspiration (FNA) is a well-established diagnostic procedure that can target most of the pulmonary lesions. Transbronchial FNA and its ancillary procedures such as bronchial washings and brushing are commonly used to diagnose centrally located tumors; however, they can also be used for diagnosis of peripheral lesions. In this study we compared the diagnostic efficacy of these two procedures. Materials and Methods: We retrospectively reviewed the records of patients who had either transthoracic or transbronchial FNA of pulmonary mass between 2010 and April 2013. FNA results were entered into the following categories: positive or suspicious for malignancy, negative, suboptimal/atypical, and inadequate. The number of needle passes and any ancillary procedures performed at the time of transbronchial FNA were recorded. Results: The 270 transthoracic FNAs included 172 positive (63.7%), 11 suspicious (4.1%), 27 inadequate (10.0%), and 18 negative (6.7%) cases (Table 1). The 83 transbronchial FNAs included 41 positive (49.4%), 7 suspicious (8.4%), 27 inadequate (32.5%), and 1 negative (1.2%) cases (Table 2). There is no significant difference in the number of needle passes between the two procedures. Ancillary procedures (bronchial brushing, washings, and lavage) were performed during 63 transbronchial aspirations and yielded 3 additional positive diagnosis (2 brushings and 1 lavage). Among the 27 inadequate transbronchial FNAs, 16 lesions were small (< 2 cm), and 13 lesions were found in challenging locations (apical and posterior segments of upper lobes and basal segments of lower lobes). Table 1
Transthoracic FNA results
Diagnosis Positive for malignancy
Squamous cell carcinoma Adenocarcinoma Non-small cell lung cancer Small cell carcinoma Poorly differentiated carcinoma Metastatic carcinoma Lymphoma
Suspicious for malignancy Suboptimal/atypical Inadequate Negative for malignancy
Table 2
HPV ISH and IHC results
Small surgical biopsies 50/55 (90%)
HPV ISH (manual)
IHC P16
39/55 (70%)
44/55 (80%)
Statistical analysis HPV ISH (automated) HPV ISH (manual) P16 IHC
Sensitivity
Specificity
PPV
NPV
Accuracy
90% 70% 80%
100% 100% 100%
100% 100% 100%
66% 38% 47%
92% 75% 83%
Number of needle passes
41 78 29 4 6 13 1 11
Average Average Average Average Average Average 3 Average
42 27 18
Average 3.6/case Average 3.5/case Average 3.1/case
Number of Cases
Number of needle passes
9 10 11 7 2 1 1 7
Average Average Average Average Average 6 5 Average
7 27 1
Average 3.1/case Average 3.0/case 3
3.2/case 3.0/case 3.5/case 3.3/case 3.3/case 3.2/case 3.8/case
Transbronchial FNA results
Diagnosis HPV ISH (automated)
Number of Cases
Positive for malignancy
Squamous cell carcinoma Adenocarcinoma Non-small cell lung cancer Small cell carcinoma Poorly differentiated carcinoma Metastatic carcinoma Carcinoid
Suspicious for malignancy Suboptimal/atypical Inadequate Negative for malignancy
4.0/case 3.3/case 3.7/case 4.0/case 2.0/case
4.7/case
S54
Abstracts
Conclusions: CT-guided transthoracic FNA is apparently more effective than transbronchial FNA in diagnosis of pulmonary cancer. Poor selection of cases, small size and complex anatomic location of the lesion are possible factors that contribute to the poor diagnostic yield in transbronchial FNAs. In addition, use of ancillary procedures does not improve its diagnostic efficacy.
124 Comparison of the Diagnostic Yield of Cytology and Concurrent Surgical Pathology Specimens by Novel Electromagnetic Navigation Bronchoscopy Brooke Koltz, MD, Donna K. Russell, MS, CT(ASCP)HT, Michael A. Nead, MD, PhD, Zhongren Zhou, MD, PhD University of Rochester, Rochester, Minnesota
123 Rapid On-Site Adequacy Evaluation (ROSE) Adds Value to Bronchoscopic Procedures Jinesh Patel, MD, Dawn Underwood, MS, CT(ASCP), Julie Shorie, CT, Jennifer A. Brainard, MD Cleveland Clinic, Cleveland, Ohio Introduction: Rapid on-site evaluation of specimen adequacy is used at many institutions to enhance diagnostic yield. Cytology personnel began routinely performing ROSE at our institution in 2010. The aim of this study is to determine the effect of ROSE on diagnostic yield at our institution. Materials and Methods: Two 4 month time periods in which the majority of bronchoscopic cytology samples were obtained either with or without ROSE were selected. All bronchoscopic procedures were included whether or not real time image guidance was used. Image-guided modalities including fluoroscopy, endobronchial ultrasound-guided FNA (EBUS) and electromagnetic navigation bronchoscopy (ENB) were used during both periods. The pre-ROSE time period was 1/1/09-4/30/09 and the postROSE time period was 1/1/12 - 4/30/12. The following data were collected: final diagnosis, number of non-diagnostic samples, number of slides per case, use of ancillary testing and number of patients requiring additional procedures. Unsatisfactory/non-diagnostic samples and all atypical categories were considered non-diagnostic. All procedures after the initial procedure were considered additional until a conclusive diagnosis was rendered. Pearson’s Chi-squared test with Yates’ continuity correction was used to determine statistical significances. Results: A total of 151 procedures were performed pre-ROSE and 246 procedures post-ROSE. Specific diagnostic categories and use of ancillary testing are summarized in Table 1. Comparison of diagnostic and non-diagnostic cases and additional diagnostic procedures performed are summarized in Table 2. Conclusions: There were significantly fewer non-diagnostic bronchoscopic samples in the post-ROSE period. Use of ancillary studies increased significantly in the post-ROSE period with more malignancies given a specific cell type. The number of additional procedures performed for definitive diagnosis decreased in the post-ROSE time period. Correlation of impact of ROSE on specific imaging modalities used in bronchoscopy is warranted Table 1
Diagnostic Categories and Ancillary Testing
Malignant Cases: With Specific Cell Type Without Specific Cell Type Total Cases Granuloma Cases Use of Ancillary Testing
Table 2
Pre-ROSE
Post-ROSE
37 (79%) 10 (21%)
120 (88%) 16 (12%)
47 2 (1.3%) 11 (7.3%)
136 36 (15%) 71 (29%)
Diagnostic versus Non-Diagnostic Cases
Total procedures Diagnostic Cases Non-Diagnostic # of Patients with Additional Procedures
Pre-ROSE
Post-ROSE
p-Value
151 125 (82.8%) 26 (17%) 29 (19%)
246 231 (93.9%) 15 (6.1%) 8 (3%)
p<0.001 p<0.001
Introduction: Electromagnetic navigation bronchoscopy (ENB) is a novel technique that allows for additional localization and sampling of peripheral lung lesions and mediastinal lymph nodes otherwise inaccessible by traditional flexible bronchoscopy. We sought to evaluate the diagnostic yield between ENB fine needle aspiration (FNA) and concurrent surgical biopsies performed by pulmonologists at our institution. Materials and Methods: Our pathology database was retrospectively queried for superDimensionÒ electromagnetic navigation bronchoscopy (Covidien, Mineapolis, MN) fine needle aspiration and brushing procedures performed at our institution during a 38 month period (January 2010 to April 2013). Eighty-six ENB FNA cases were identified from our database as well as sixty-eight matched concurrent surgical biopsies. The diagnoses from both ENB FNA and ENB biopsy were compared and analyzed. The slides were re-reviewed on all cases showing discordant results. Results: ENB was employed on 85 cases during our study time interval, and concurrent surgical biopsies were obtained on 68 (80%) cases. On cytology, 35 of 85 cases (41%) were diagnosed as suspicious for malignancy or malignant, 46 (54%) cases were negative or atypical, and 4 (5%) cases were insufficient. On concurrent surgical biopsy, 28 of 68 cases (41%) were diagnosed as suspicious for malignancy or malignant, 39 (57%) were negative or atypical, and 1 (1%) case was insufficient. The rates of diagnoses between cytology and concurrent surgical biopsy specimens for malignant, negative, and non-diagnostic categories were comparable and were not statistically significant (pZ1, pZ0.74, pZ0.38 respectively). Of the cytology cases with matched concurrent surgical biopsies, there were seven (10%) cases with major discordant diagnoses (see Table 1). One case proved to be a false negative upon re-review. Conclusions: Novel ENB FNA is a unique and reliable technique for sampling peripheral lung lesions and is comparable to surgical biopsy. Table 1
Matched cytology and surgical pathology diagnoses
Surgical Diagnoses
Cytology Diagnoses Nondiagnostic
Nondiagnostic Negative/Atypical Suspicious Malignant Cytology Totals
1 2
3
Negative/ Atypical
Suspicious
Malignant
32 1 4 37
2
3 1 19 23
3 5
Surgical Totals 1 39 2 26 68
125 Cytomorphologic, Immunohistochemical and Molecular Features of Poorly Differentiated Non-Small Cell Lung Carcinomas Zaibo Li, MD, PhD, Sanja Dacic, MD, PhD, Liron Pantanowitz, MD, MIAC, Walid E. Khalbuss, MD, PhD, FIAC, Marina Nikiforova, MD, Sara E. Monaco, MD University of Pittsburgh Pathology, Pittsburgh, Pennsylvania Introduction: The subclassification of non-small cell lung carcinoma (NSCLC) is important for treatment decisions. However, cases of poorly
S53
Conclusions: Including head and neck tissue samples into the automated extraction system avoids manual processes, and decreases the chance of error. It has the advantage of including these cases into the routine cervical sample HPV runs. This eliminates the need for small kit sizes and longer intervals between runs, keeping costs lower and improving TAT for head and neck samples. It also provides a comparable alternative to ISH testing for FFPE samples. Table 1 Roche Sensitivity Roche Specificity NPV PPV
1.00 0.91 1.00 0.91
ISH Sensitivity ISH Specificity NPV PPV
0.97 0.97 0.97 0.97
121 Comparing Automated with Manual HPV, ISH, AND P16 Immunohistochemistry in Assessing Oropharyngeal Carcinoma (OPC) Nazneen Fatima, MD, Cynthia Cohen, MD, Momin T. Siddiqui, MD Emory University, Atlanta, Georgia Introduction: HPV-positive tumors comprise a unique subset of head and neck squamous cell carcinomas (HNSCCs) that are different from HPVnegative tumors in respect to tumor differentiation, genetic changes, risk factors, risk stratification and prognosis. Detection of HPV status is now a standard practice in the pathologic evaluation of HNSCCs. Determining the integration status of HPV by in situ hybridization (ISH) is cost effective and routinely utilized in clinical practice. Strong correlations have been reported between diffuse nuclear and cytoplasmic p16 immunohistochemical staining (IHC) and HPV DNA detection by ISH. In this study, we compared the efficacy of automated HPV ISH utilizing the Enzo probe with manual HPV ISH utilizing the Dako probe, and P16 IHC in the evaluation of OPCs. Materials and Methods: A total of 55 OPC small surgical biopsies were evaluated with automated HPV ISH utilizing the Enzo probe, the manual HPV ISH with the Dako probe, and P16 IHC. HPV ISH was interpreted as positive if a minimum of one tumor cell showed punctate dot like nuclear positivity. P16 was interpreted as positive if 70% of tumor cells showed brown nuclear and cytoplasmic staining. 10 small surgical biopsies from lung squamous cell carcinoma were studied as negative controls. Results: Fifty of 55 cases (90%) were positive for automated HPV ISH; 39 of 55 cases (70%) with manual HPV ISH. Forty four of 55 (80%) cases were positive for P16 IHC. Conclusions: In comparing automated HPV ISH utilizing Enzo probe with manual HPV ISH utilizing the Dako probe, and P16 IHC, we have determined that automated HPV ISH plays a more significant role in determining the HPV status in surgical biopsies as compared to the other two techniques. P16 staining is easier to recognize and evaluate on tumor cells in contrast to punctate dot like positivity seen in HPV ISH which may be very focal and requires careful evaluation at a higher magnification.
LUNG AND MEDIASTINUM 122 Diagnostic Efficacy of Transthoracic and Transbronchial Fine Needle Aspiration: A Single Institution Experience Congli Wang, MD, Varsha Manucha, MD, Michael J. Carrozza, BS, Yajue Huang, MD, PhD Temple University Hospital, Philadelphia, Pennsylvania Introduction: CT-guided transthoracic fine needle aspiration (FNA) is a well-established diagnostic procedure that can target most of the pulmonary lesions. Transbronchial FNA and its ancillary procedures such as bronchial washings and brushing are commonly used to diagnose centrally located tumors; however, they can also be used for diagnosis of peripheral lesions. In this study we compared the diagnostic efficacy of these two procedures. Materials and Methods: We retrospectively reviewed the records of patients who had either transthoracic or transbronchial FNA of pulmonary mass between 2010 and April 2013. FNA results were entered into the following categories: positive or suspicious for malignancy, negative, suboptimal/atypical, and inadequate. The number of needle passes and any ancillary procedures performed at the time of transbronchial FNA were recorded. Results: The 270 transthoracic FNAs included 172 positive (63.7%), 11 suspicious (4.1%), 27 inadequate (10.0%), and 18 negative (6.7%) cases (Table 1). The 83 transbronchial FNAs included 41 positive (49.4%), 7 suspicious (8.4%), 27 inadequate (32.5%), and 1 negative (1.2%) cases (Table 2). There is no significant difference in the number of needle passes between the two procedures. Ancillary procedures (bronchial brushing, washings, and lavage) were performed during 63 transbronchial aspirations and yielded 3 additional positive diagnosis (2 brushings and 1 lavage). Among the 27 inadequate transbronchial FNAs, 16 lesions were small (< 2 cm), and 13 lesions were found in challenging locations (apical and posterior segments of upper lobes and basal segments of lower lobes). Table 1
Transthoracic FNA results
Diagnosis Positive for malignancy
Squamous cell carcinoma Adenocarcinoma Non-small cell lung cancer Small cell carcinoma Poorly differentiated carcinoma Metastatic carcinoma Lymphoma
Suspicious for malignancy Suboptimal/atypical Inadequate Negative for malignancy
Table 2
HPV ISH and IHC results
Small surgical biopsies 50/55 (90%)
HPV ISH (manual)
IHC P16
39/55 (70%)
44/55 (80%)
Statistical analysis HPV ISH (automated) HPV ISH (manual) P16 IHC
Sensitivity
Specificity
PPV
NPV
Accuracy
90% 70% 80%
100% 100% 100%
100% 100% 100%
66% 38% 47%
92% 75% 83%
Number of needle passes
41 78 29 4 6 13 1 11
Average Average Average Average Average Average 3 Average
42 27 18
Average 3.6/case Average 3.5/case Average 3.1/case
Number of Cases
Number of needle passes
9 10 11 7 2 1 1 7
Average Average Average Average Average 6 5 Average
7 27 1
Average 3.1/case Average 3.0/case 3
3.2/case 3.0/case 3.5/case 3.3/case 3.3/case 3.2/case 3.8/case
Transbronchial FNA results
Diagnosis HPV ISH (automated)
Number of Cases
Positive for malignancy
Squamous cell carcinoma Adenocarcinoma Non-small cell lung cancer Small cell carcinoma Poorly differentiated carcinoma Metastatic carcinoma Carcinoid
Suspicious for malignancy Suboptimal/atypical Inadequate Negative for malignancy
4.0/case 3.3/case 3.7/case 4.0/case 2.0/case
4.7/case
S54
Abstracts
Conclusions: CT-guided transthoracic FNA is apparently more effective than transbronchial FNA in diagnosis of pulmonary cancer. Poor selection of cases, small size and complex anatomic location of the lesion are possible factors that contribute to the poor diagnostic yield in transbronchial FNAs. In addition, use of ancillary procedures does not improve its diagnostic efficacy.
124 Comparison of the Diagnostic Yield of Cytology and Concurrent Surgical Pathology Specimens by Novel Electromagnetic Navigation Bronchoscopy Brooke Koltz, MD, Donna K. Russell, MS, CT(ASCP)HT, Michael A. Nead, MD, PhD, Zhongren Zhou, MD, PhD University of Rochester, Rochester, Minnesota
123 Rapid On-Site Adequacy Evaluation (ROSE) Adds Value to Bronchoscopic Procedures Jinesh Patel, MD, Dawn Underwood, MS, CT(ASCP), Julie Shorie, CT, Jennifer A. Brainard, MD Cleveland Clinic, Cleveland, Ohio Introduction: Rapid on-site evaluation of specimen adequacy is used at many institutions to enhance diagnostic yield. Cytology personnel began routinely performing ROSE at our institution in 2010. The aim of this study is to determine the effect of ROSE on diagnostic yield at our institution. Materials and Methods: Two 4 month time periods in which the majority of bronchoscopic cytology samples were obtained either with or without ROSE were selected. All bronchoscopic procedures were included whether or not real time image guidance was used. Image-guided modalities including fluoroscopy, endobronchial ultrasound-guided FNA (EBUS) and electromagnetic navigation bronchoscopy (ENB) were used during both periods. The pre-ROSE time period was 1/1/09-4/30/09 and the postROSE time period was 1/1/12 - 4/30/12. The following data were collected: final diagnosis, number of non-diagnostic samples, number of slides per case, use of ancillary testing and number of patients requiring additional procedures. Unsatisfactory/non-diagnostic samples and all atypical categories were considered non-diagnostic. All procedures after the initial procedure were considered additional until a conclusive diagnosis was rendered. Pearson’s Chi-squared test with Yates’ continuity correction was used to determine statistical significances. Results: A total of 151 procedures were performed pre-ROSE and 246 procedures post-ROSE. Specific diagnostic categories and use of ancillary testing are summarized in Table 1. Comparison of diagnostic and non-diagnostic cases and additional diagnostic procedures performed are summarized in Table 2. Conclusions: There were significantly fewer non-diagnostic bronchoscopic samples in the post-ROSE period. Use of ancillary studies increased significantly in the post-ROSE period with more malignancies given a specific cell type. The number of additional procedures performed for definitive diagnosis decreased in the post-ROSE time period. Correlation of impact of ROSE on specific imaging modalities used in bronchoscopy is warranted Table 1
Diagnostic Categories and Ancillary Testing
Malignant Cases: With Specific Cell Type Without Specific Cell Type Total Cases Granuloma Cases Use of Ancillary Testing
Table 2
Pre-ROSE
Post-ROSE
37 (79%) 10 (21%)
120 (88%) 16 (12%)
47 2 (1.3%) 11 (7.3%)
136 36 (15%) 71 (29%)
Diagnostic versus Non-Diagnostic Cases
Total procedures Diagnostic Cases Non-Diagnostic # of Patients with Additional Procedures
Pre-ROSE
Post-ROSE
p-Value
151 125 (82.8%) 26 (17%) 29 (19%)
246 231 (93.9%) 15 (6.1%) 8 (3%)
p<0.001 p<0.001
Introduction: Electromagnetic navigation bronchoscopy (ENB) is a novel technique that allows for additional localization and sampling of peripheral lung lesions and mediastinal lymph nodes otherwise inaccessible by traditional flexible bronchoscopy. We sought to evaluate the diagnostic yield between ENB fine needle aspiration (FNA) and concurrent surgical biopsies performed by pulmonologists at our institution. Materials and Methods: Our pathology database was retrospectively queried for superDimensionÒ electromagnetic navigation bronchoscopy (Covidien, Mineapolis, MN) fine needle aspiration and brushing procedures performed at our institution during a 38 month period (January 2010 to April 2013). Eighty-six ENB FNA cases were identified from our database as well as sixty-eight matched concurrent surgical biopsies. The diagnoses from both ENB FNA and ENB biopsy were compared and analyzed. The slides were re-reviewed on all cases showing discordant results. Results: ENB was employed on 85 cases during our study time interval, and concurrent surgical biopsies were obtained on 68 (80%) cases. On cytology, 35 of 85 cases (41%) were diagnosed as suspicious for malignancy or malignant, 46 (54%) cases were negative or atypical, and 4 (5%) cases were insufficient. On concurrent surgical biopsy, 28 of 68 cases (41%) were diagnosed as suspicious for malignancy or malignant, 39 (57%) were negative or atypical, and 1 (1%) case was insufficient. The rates of diagnoses between cytology and concurrent surgical biopsy specimens for malignant, negative, and non-diagnostic categories were comparable and were not statistically significant (pZ1, pZ0.74, pZ0.38 respectively). Of the cytology cases with matched concurrent surgical biopsies, there were seven (10%) cases with major discordant diagnoses (see Table 1). One case proved to be a false negative upon re-review. Conclusions: Novel ENB FNA is a unique and reliable technique for sampling peripheral lung lesions and is comparable to surgical biopsy. Table 1
Matched cytology and surgical pathology diagnoses
Surgical Diagnoses
Cytology Diagnoses Nondiagnostic
Nondiagnostic Negative/Atypical Suspicious Malignant Cytology Totals
1 2
3
Negative/ Atypical
Suspicious
Malignant
32 1 4 37
2
3 1 19 23
3 5
Surgical Totals 1 39 2 26 68
125 Cytomorphologic, Immunohistochemical and Molecular Features of Poorly Differentiated Non-Small Cell Lung Carcinomas Zaibo Li, MD, PhD, Sanja Dacic, MD, PhD, Liron Pantanowitz, MD, MIAC, Walid E. Khalbuss, MD, PhD, FIAC, Marina Nikiforova, MD, Sara E. Monaco, MD University of Pittsburgh Pathology, Pittsburgh, Pennsylvania Introduction: The subclassification of non-small cell lung carcinoma (NSCLC) is important for treatment decisions. However, cases of poorly