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Unsatisfactory, Negative, and Atypical Lung Biopsies: True Negatives or False Negatives?
Abstracts
S83
EBUS FNA of Primary Pulmonary Non-Small Cell Carcinoma and Surgical Pathology Correlation Cases Correlation Cases
Cases
Specific Category Agreement Non-Small Cell Carcinoma Total Cases
8 2 10
EBUS FNAZEndobronchial Ultrasound Guided Fine Needle Aspiration EBUS FNA of Primary Pulmonary Non-Small Cell Carcinoma and Surgical Pathology Non-Correlation Cases Non-Correlation Categories
Cases
EBUS FNA Diagnostic and SP Nondiagnostic EBUS FNA More Specific Diagnostic Category than Surgical Pathology Surgical Pathology More Specific Diagnostic Category than EBUS FNA Total Cases
5 5 2 12
EBUS FNAZEndobronchial Ultrasound Guided Fine Needle Aspiration
Conclusions: In 76 patients with primary pulmonary non-small cell carcinoma, a panel of IHC stains performed on the cell block was able to provide a specific diagnostic category in 83% of cases. In 72% of cases, a pattern of dual affirmative markers were present (i.e. positive napsin/TTF and negative p63/CK/5/6 in ADCA). In 17% of cases, a diagnosis of NSCCA was not further categorized by IHC. Of 22 cases with SP, there was correlation in 10 with FNA being more specific in an additional 5 cases. EBUS FNA with an immunohistochemistry panel performed on the cell block can provide a specific diagnosis of adenocarcinoma and squamous cell carcinoma in primary pulmonary non-small cell carcinoma. 149 Unsatisfactory, Negative, and Atypical Lung Biopsies: True Negatives or False Negatives? John Crapanzano, Shana Coley, Anjali Saqi. Pathology and Cell Biology, Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York Introduction: Fine-needle aspiration (FNA) and core biopsies are often performed to characterize lung masses/nodules. While a positive (P) or suspicious (S) report provides sufficient information to warrant treatment and/or further intervention, the significance of unsatisfactory (U), negative (N), and atypical (A) diagnoses remains uncertain. The aim of the current study was to determine if U, N, and A aspirates and core biopsy touch preparations (CBTPs) represent true negatives (TNs) or false negatives warranting repeat biopsy. Materials and Methods: We performed a computerized search and examined 30 consecutive CT-guided transthoracic U, N, and A lung FNAs (23) and CBTPs (7) with surgical pathology (SP) (16) or clinical follow-up (14) and compared them to 10 SP-confirmed P FNAs, which served as controls. Cytomorphological findings evaluated included epithelial cellularity, epithelial arrangement, cell size, nuclear features, cytoplasmic vacuolization, macrophages, multinucleated giant cells (MNG), inflammation, granulomas, necrosis, and mucus. Results: The U (6), N (13) and A (11) FNAs and TPs were from 29 patients (19 females; 10 males; age range 16-82; average age 61). Cytologic findings are summarized in the Table. All 6 U specimens were scantly cellular with too few cells for a diagnosis. The N cases showed granulomatous inflammation (6), limited cellularity (3), acute inflammation (1), reactive epithelioid cells (1), bland epithelial/ epithelioid cells, macrophages, and inflammation (1), and necrosis associated with hemosiderin-laden macrophages (1) that appeared non-diagnostic on rereview. Of the A cases, 2 contained rare atypical cells insufficient to render a specific diagnosis (1 appeared negative on re-review). Of the remaining 9 A cases, 8 contained few atypical cells that were either favored to be reactive at the time of diagnosis or upon re-review, and 1 had a few atypical epithelioid cells. The P cases were from 10 patients (7 females; 3 males; age range 55-86; average age: 68). Final SP diagnoses were adenocarcinoma (9/10) and adenosquamous carcinoma (1/10). Cytologic findings are summarized in the Table.
Cytomorphological Findings Cytologic Features
U, N, and A Aspirates
P Aspirates
Epithelial Cells Epithelial Sheets Epithelial 3-D Clusters Epithelial Acinar Arrangements Epithelial Single Cells Epithelial Cell Size (a) Nuclear Irregularity (b) Hyperchromasia (b) Nucleoli (c)
22/30 15/22 0/22 0/22 22/22 6.6 0: 15/22 1: 7/22 0: 22/22 1: 18/22 2: 4/22
Cytoplasmic Vacuoles (d) Macrophages Multinucleated Giant Cells Inflammation Necrosis Mucus
FV (nZ13) 29/30 18/30 25/30 10/30 3/30
10/10 6/10 10/10 10/10 10/10 10.5 2: 5/10 3: 5/10 2: 7/10 3: 3/10 0: 2/10, 1: 3/10, 2: 3/10, 3: 2/10 FV (nZ8) LG (nZ3) 8/10 3/10 6/10 2/10 0/10
(a) average cell size relative to a RBC. (b) 0: absent, 1: mild, 2: moderate, 3: marked. (c) 0: absent, 1: pinpoint, 2: conspicuous, 3: macro. (d) FV: finely vacuolated; LGZmoderate-to-large vacuoles.
Overall, U, N, and A cases tended to be sparsely cellular, associated with inflammatory cells and MNG, and when present, the atypia corresponded to reactive type II pneumocytes. Cases with SP follow-up showed non-neoplastic findings including organizing pneumonia (5), granulomas (7), infarct (1), necrosis (1), fibrous tissue with focal type II hyperplasia (1), and non-diagnostic (1). The epithelial cells on the cytological preparations represented pneumocyte hyperplasia/hobnail pattern on SP (11/16). Cases of organizing pneumonia were sparsely cellular. Clinical/radiologic follow-up (2-48 weeks; average 20 weeks) of the remaining 14 cases showed that the lung lesions either decreased in size/resolved completely (12) or remained stable (2). Conclusions: In conclusion, U, N, and A FNAS and CBTPs tend to represent TNs, especially in the presence of granulomas and absence of 3-D clusters, acinar formation, significant nuclear irregularity, and hyperchromasia. In sparsely cellular specimens, a core biopsy may be requested at the time of on-site assessment to confirm the TN impression in the setting of a nodule/mass. Additional data and correlation with clinical and radiological findings, however, are necessary to corroborate these results. 150 A Review of Lung Fine Needle Aspiration Biopsies with Cytohistologic Correlation of Pulmonary Lesions: An Academic Medical Center Experience Feriyl Bhaijee, MD, Nivin Ishaq, MD, Anwer Siddiqi, MD, Israh Akhtar, MD. Pathology, University of Mississippi Medical Center, Jackson, Mississippi Introduction: Fine needle aspiration biopsy (FNAB) is commonly used in the evaluation of pulmonary nodules. In our setting, the high prevalence of lung malignancies and the often advanced stage at diagnosis frequently preclude post-FNA surgical intervention. Thus, lung FNAB is often the only diagnostic modality employed in the workup of pulmonary nodules. The diagnostic accuracy of lung FNAB, however, varies significantly based on operator experience, technical difficulties, and patient-specific factors. In this study, we reviewed lung FNABs and correlated FNAB results with subsequent histopathologic diagnoses in order to evaluate the diagnostic accuracy of lung FNAB at our institution. Materials and Methods: We reviewed all lung FNABs performed at a large academic medical center between 01/2007 and 06/2011 and identified patients that underwent subsequent surgical excision or resection. For each patient, we collected the following data: age, sex, FNAB results, and final histopathologic diagnoses. Results: Over a 4.5-year period, 489 lung FNABs were performed at our institution: 19 (4%) were unsatisfactory for evaluation, 174 (36%) were negative for malignancy, 7 (1%) were atypical, 22 (4%) were suspicious, and 267 (55%) were positive for malignancy. Of these, 110 (22%)
S83
EBUS FNA of Primary Pulmonary Non-Small Cell Carcinoma and Surgical Pathology Correlation Cases Correlation Cases
Cases
Specific Category Agreement Non-Small Cell Carcinoma Total Cases
8 2 10
EBUS FNAZEndobronchial Ultrasound Guided Fine Needle Aspiration EBUS FNA of Primary Pulmonary Non-Small Cell Carcinoma and Surgical Pathology Non-Correlation Cases Non-Correlation Categories
Cases
EBUS FNA Diagnostic and SP Nondiagnostic EBUS FNA More Specific Diagnostic Category than Surgical Pathology Surgical Pathology More Specific Diagnostic Category than EBUS FNA Total Cases
5 5 2 12
EBUS FNAZEndobronchial Ultrasound Guided Fine Needle Aspiration
Conclusions: In 76 patients with primary pulmonary non-small cell carcinoma, a panel of IHC stains performed on the cell block was able to provide a specific diagnostic category in 83% of cases. In 72% of cases, a pattern of dual affirmative markers were present (i.e. positive napsin/TTF and negative p63/CK/5/6 in ADCA). In 17% of cases, a diagnosis of NSCCA was not further categorized by IHC. Of 22 cases with SP, there was correlation in 10 with FNA being more specific in an additional 5 cases. EBUS FNA with an immunohistochemistry panel performed on the cell block can provide a specific diagnosis of adenocarcinoma and squamous cell carcinoma in primary pulmonary non-small cell carcinoma. 149 Unsatisfactory, Negative, and Atypical Lung Biopsies: True Negatives or False Negatives? John Crapanzano, Shana Coley, Anjali Saqi. Pathology and Cell Biology, Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York Introduction: Fine-needle aspiration (FNA) and core biopsies are often performed to characterize lung masses/nodules. While a positive (P) or suspicious (S) report provides sufficient information to warrant treatment and/or further intervention, the significance of unsatisfactory (U), negative (N), and atypical (A) diagnoses remains uncertain. The aim of the current study was to determine if U, N, and A aspirates and core biopsy touch preparations (CBTPs) represent true negatives (TNs) or false negatives warranting repeat biopsy. Materials and Methods: We performed a computerized search and examined 30 consecutive CT-guided transthoracic U, N, and A lung FNAs (23) and CBTPs (7) with surgical pathology (SP) (16) or clinical follow-up (14) and compared them to 10 SP-confirmed P FNAs, which served as controls. Cytomorphological findings evaluated included epithelial cellularity, epithelial arrangement, cell size, nuclear features, cytoplasmic vacuolization, macrophages, multinucleated giant cells (MNG), inflammation, granulomas, necrosis, and mucus. Results: The U (6), N (13) and A (11) FNAs and TPs were from 29 patients (19 females; 10 males; age range 16-82; average age 61). Cytologic findings are summarized in the Table. All 6 U specimens were scantly cellular with too few cells for a diagnosis. The N cases showed granulomatous inflammation (6), limited cellularity (3), acute inflammation (1), reactive epithelioid cells (1), bland epithelial/ epithelioid cells, macrophages, and inflammation (1), and necrosis associated with hemosiderin-laden macrophages (1) that appeared non-diagnostic on rereview. Of the A cases, 2 contained rare atypical cells insufficient to render a specific diagnosis (1 appeared negative on re-review). Of the remaining 9 A cases, 8 contained few atypical cells that were either favored to be reactive at the time of diagnosis or upon re-review, and 1 had a few atypical epithelioid cells. The P cases were from 10 patients (7 females; 3 males; age range 55-86; average age: 68). Final SP diagnoses were adenocarcinoma (9/10) and adenosquamous carcinoma (1/10). Cytologic findings are summarized in the Table.
Cytomorphological Findings Cytologic Features
U, N, and A Aspirates
P Aspirates
Epithelial Cells Epithelial Sheets Epithelial 3-D Clusters Epithelial Acinar Arrangements Epithelial Single Cells Epithelial Cell Size (a) Nuclear Irregularity (b) Hyperchromasia (b) Nucleoli (c)
22/30 15/22 0/22 0/22 22/22 6.6 0: 15/22 1: 7/22 0: 22/22 1: 18/22 2: 4/22
Cytoplasmic Vacuoles (d) Macrophages Multinucleated Giant Cells Inflammation Necrosis Mucus
FV (nZ13) 29/30 18/30 25/30 10/30 3/30
10/10 6/10 10/10 10/10 10/10 10.5 2: 5/10 3: 5/10 2: 7/10 3: 3/10 0: 2/10, 1: 3/10, 2: 3/10, 3: 2/10 FV (nZ8) LG (nZ3) 8/10 3/10 6/10 2/10 0/10
(a) average cell size relative to a RBC. (b) 0: absent, 1: mild, 2: moderate, 3: marked. (c) 0: absent, 1: pinpoint, 2: conspicuous, 3: macro. (d) FV: finely vacuolated; LGZmoderate-to-large vacuoles.
Overall, U, N, and A cases tended to be sparsely cellular, associated with inflammatory cells and MNG, and when present, the atypia corresponded to reactive type II pneumocytes. Cases with SP follow-up showed non-neoplastic findings including organizing pneumonia (5), granulomas (7), infarct (1), necrosis (1), fibrous tissue with focal type II hyperplasia (1), and non-diagnostic (1). The epithelial cells on the cytological preparations represented pneumocyte hyperplasia/hobnail pattern on SP (11/16). Cases of organizing pneumonia were sparsely cellular. Clinical/radiologic follow-up (2-48 weeks; average 20 weeks) of the remaining 14 cases showed that the lung lesions either decreased in size/resolved completely (12) or remained stable (2). Conclusions: In conclusion, U, N, and A FNAS and CBTPs tend to represent TNs, especially in the presence of granulomas and absence of 3-D clusters, acinar formation, significant nuclear irregularity, and hyperchromasia. In sparsely cellular specimens, a core biopsy may be requested at the time of on-site assessment to confirm the TN impression in the setting of a nodule/mass. Additional data and correlation with clinical and radiological findings, however, are necessary to corroborate these results. 150 A Review of Lung Fine Needle Aspiration Biopsies with Cytohistologic Correlation of Pulmonary Lesions: An Academic Medical Center Experience Feriyl Bhaijee, MD, Nivin Ishaq, MD, Anwer Siddiqi, MD, Israh Akhtar, MD. Pathology, University of Mississippi Medical Center, Jackson, Mississippi Introduction: Fine needle aspiration biopsy (FNAB) is commonly used in the evaluation of pulmonary nodules. In our setting, the high prevalence of lung malignancies and the often advanced stage at diagnosis frequently preclude post-FNA surgical intervention. Thus, lung FNAB is often the only diagnostic modality employed in the workup of pulmonary nodules. The diagnostic accuracy of lung FNAB, however, varies significantly based on operator experience, technical difficulties, and patient-specific factors. In this study, we reviewed lung FNABs and correlated FNAB results with subsequent histopathologic diagnoses in order to evaluate the diagnostic accuracy of lung FNAB at our institution. Materials and Methods: We reviewed all lung FNABs performed at a large academic medical center between 01/2007 and 06/2011 and identified patients that underwent subsequent surgical excision or resection. For each patient, we collected the following data: age, sex, FNAB results, and final histopathologic diagnoses. Results: Over a 4.5-year period, 489 lung FNABs were performed at our institution: 19 (4%) were unsatisfactory for evaluation, 174 (36%) were negative for malignancy, 7 (1%) were atypical, 22 (4%) were suspicious, and 267 (55%) were positive for malignancy. Of these, 110 (22%)