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Molecular Testing for Pulmonary Adenocarcinoma and Non-Small Cell Carcinoma on Cytological Specimens- A Single Institution Experience
S86
Abstracts
TBFNA) is essential to obtain adequate samples and provide a preliminary diagnosis. Distance and time constraints make ROSE of EUS-TBFNA time consuming. We present our experience with ROSE of EBUS-TFNA using telecytopathology. Materials and Methods: Real time images of Diff Quik stained cytology smears were obtained with an Olympus digital camera attached to an Olympus CX41 microscope. Cytopathologist accessing the dynamic images on a computer rendered preliminary diagnosis while communicating with the on-site operator via Vocera voice communication system. Accuracy of ROSE via telecytopathology was compared with equal number of cases that received ROSE, prior to introduction of telecytopathology, via conventional microscopy. Results: Rapid on-site evaluation was performed on a total of 200 EBUSTBFNAs. Telecytopathology system and conventional microscopy were used to evaluate equal number of cases (100 each). Preliminary diagnoses of negative/benign, atypical /suspicious and positive for malignancy were 58%, 14% and 24% for telecytopathology and 60%, 9% and 31% for conventional microscopy. Four percent of telecytopathology cases and 2% of conventional microscopy cases were deemed unsatisfactory at the time of ROSE. The overall concordance between the preliminary and final diagnoses was 96% for telecytopathology and 93 % for conventional microscopy. The causes of discordant preliminary and final diagnoses could be mainly attributed to difficulty in distinguishing small cell carcinoma versus reactive lymph node due to crush artifact, atypia related to reactive bronchial epithelial cells, and availability of cell block material and Pap stained slides for review at the time of final cytologic sign out. Conclusions: Telecytopathology is comparable with conventional microscopy in ROSE of EBUS-TBFNA. It can serve as a valid substitute for conventional microscopy for on-site assessment of EBUS-TBFNA, thereby, allowing cytopathologists to make real time consultation from remote site and utilize their time more effectively.
Table 1 Distribution of specimens by diagnoses and procedure type with number of tests with insufficient material for molecular testing
156
Amanda Maskovyak, MD, Kathryn Dyhdalo, MD, Jennifer Brainard, MD, Christine Booth, MD. Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio
Molecular Testing for Pulmonary Adenocarcinoma and Non-Small Cell Carcinoma on Cytological Specimens- A Single Institution Experience Srividya Sathiyamoorthy, MBBS, MS, Christina Adams, CT(ASCP), Yener Erozan, MD. Pathology, The Johns Hopkins Medical Institutions, Baltimore, Maryland Introduction: Molecular testing for mutational status of Kirsten Rat Sarcoma (KRAS), Epidermal Growth Factor Receptor (EGFR) and Anaplastic Lymphoma Kinase (ALK) in lung adenocarcinoma is an integral component of clinical management. These mutations are thought to be mutually exclusive, such that they should be tested in an algorithmic manner. Since up to 70% of patients present at an inoperable stage, cytology and small biopsy specimens are increasingly used as the only source of tissue for testing and play a critical role in the selection of appropriate chemotherapeutic agents. Materials and Methods: A retrospective analysis of molecular testing for KRAS, EGFR and ALK mutations over a 5-year period in a large tertiary care center was performed. There were 168 cases of lung adenocarcinoma and non-small cell lung carcinoma that had undergone testing for one, two or all three mutations. All the testing was performed on cell block material from EBUS-guided, transthoracic (TT) or transbronchial (TBNA) needle aspirations, pleural fluids (PF) or FNAs from distant metastatic sites. Results: The distribution of specimens by diagnoses and procedure type is displayed in Table 1. There was insufficient material for KRAS/EGFR testing in 15/168 (8.9%) specimens (Table 1). Four of these cases had sufficient material for ALK testing. Nineteen cases had surgical specimens, 3 of which had molecular testing performed on them. Two of the three cases also had molecular testing performed on cytologic material. Test results by mutation are shown in Table 2. Eight cases that had a KRAS mutation had EGFR testing also performed, while in 34 such cases, EGFR testing was appropriately canceled subsequent to a positive KRAS mutation. Turn-around-time (TAT) for KRAS, EGFR and ALK testing was approximately 1 week-10 days, 2-2.5 weeks and 1 week respectively.
Specimens Adenocarcinoma NSCLC Insufficient (percentage)
EBUS-FNA
TT
TBNA
PF
Other
80 70 10 5 (6%)
12 12 0 2 (16%)
8 7 1 0
23 21 2 2 (8.6%)
45 42 3 6 (13%)
EBUS: Endobronchial ultrasound FNA: Fine needle aspiration TT: Transthoracic TBNA- Transbronchial needle aspiration PF: Pleural fluid Table 2
Distribution of test results by mutation
Test
KRAS
EGFR
ALK
Performed Positive Negative
129 44 87
131 14 83
44 3 41
Conclusions: Cytologic material can be efficiently used for molecular testing in lung adenocarcinomas. Specimens acquired by EBUS and transthoracic procedures have the lowest and highest rates of insufficient material for molecular tests respectively. There is a need for an effective Standard Operating Procedure to optimally utilize the limited cytologic material while keeping the TAT as short as possible. Availability of clinical information is critical so as to not perform redundant immunohistochemical/molecular tests in patients who have already been tested in outside facilities. An algorithmic approach and coordination with histology can avoid redundant in-house testing. 157 Rapid On-site Evaluation of Pulmonary Samples: Correlation between Cytology and Surgical Pathology Diagnoses of Non-small Cell Carcinoma
Introduction: Rapid on-site evaluation (ROSE) of pulmonary cytologic samples improves diagnostic yield in sampling of lung masses and mediastinal/hilar lymph nodes. In addition to confirmation of an adequate sample, ROSE allows triage of material for ancillary testing and facilitates communication between patient care teams. This should result in an increased ability to make a more specific cytologic diagnosis with definitive cell typing of non-small cell carcinoma. Our institution began ROSE of pulmonary cytologic specimens in 2008. The goal of this study is to assess the accuracy and completeness of cytologic diagnosis in comparison to final surgical diagnosis. Materials and Methods: Following Institutional Review Board approval, all cases with ROSE by a cytopathologist from 2008-2011 were extracted from the anatomic pathology database. All cases that included both a cytology specimen (FNA, brushing, washing) and a surgical biopsy or resection specimen with a positive (or suspicious) diagnosis of non-small cell carcinoma (NSCC) in the lung were included. Patient age, gender, final cytology and surgical pathology diagnoses, and use of immunostains were recorded in each case. Concordance of the cytologic and surgical diagnoses was determined as follows: Concordant - the same diagnosis was reached in both cytology and surgical specimens (ex. Adenocarcinoma, squamous cell carcinoma, or NSCC); partially concordant - A diagnosis of malignancy was made, but the cytology or surgical specimens were more or less specific (ex. NSCC on cytology and adenocarcinoma on biopsy). Results: In a three year time period, a total of 164 cases from 160 patients that had a positive (or suspicious) non-small cell carcinoma diagnosis on a cytology or surgical specimen were obtained. 85 (53%) patients were female and 77 (47%) were male. Their ages ranged from 26 to 89 years (median 68 years). Of the 164 cases, 154 had positive diagnoses and the remaining 11 were suspicious for carcinoma on the cytology or surgical specimens. In the cases that were definitively diagnostic, 97 (59%) were concordant and 16 (10%) were partially concordant. Of the concordant cases, 39 (40%) had immunostains done on the cytology or surgical specimen. Of the
Abstracts
TBFNA) is essential to obtain adequate samples and provide a preliminary diagnosis. Distance and time constraints make ROSE of EUS-TBFNA time consuming. We present our experience with ROSE of EBUS-TFNA using telecytopathology. Materials and Methods: Real time images of Diff Quik stained cytology smears were obtained with an Olympus digital camera attached to an Olympus CX41 microscope. Cytopathologist accessing the dynamic images on a computer rendered preliminary diagnosis while communicating with the on-site operator via Vocera voice communication system. Accuracy of ROSE via telecytopathology was compared with equal number of cases that received ROSE, prior to introduction of telecytopathology, via conventional microscopy. Results: Rapid on-site evaluation was performed on a total of 200 EBUSTBFNAs. Telecytopathology system and conventional microscopy were used to evaluate equal number of cases (100 each). Preliminary diagnoses of negative/benign, atypical /suspicious and positive for malignancy were 58%, 14% and 24% for telecytopathology and 60%, 9% and 31% for conventional microscopy. Four percent of telecytopathology cases and 2% of conventional microscopy cases were deemed unsatisfactory at the time of ROSE. The overall concordance between the preliminary and final diagnoses was 96% for telecytopathology and 93 % for conventional microscopy. The causes of discordant preliminary and final diagnoses could be mainly attributed to difficulty in distinguishing small cell carcinoma versus reactive lymph node due to crush artifact, atypia related to reactive bronchial epithelial cells, and availability of cell block material and Pap stained slides for review at the time of final cytologic sign out. Conclusions: Telecytopathology is comparable with conventional microscopy in ROSE of EBUS-TBFNA. It can serve as a valid substitute for conventional microscopy for on-site assessment of EBUS-TBFNA, thereby, allowing cytopathologists to make real time consultation from remote site and utilize their time more effectively.
Table 1 Distribution of specimens by diagnoses and procedure type with number of tests with insufficient material for molecular testing
156
Amanda Maskovyak, MD, Kathryn Dyhdalo, MD, Jennifer Brainard, MD, Christine Booth, MD. Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio
Molecular Testing for Pulmonary Adenocarcinoma and Non-Small Cell Carcinoma on Cytological Specimens- A Single Institution Experience Srividya Sathiyamoorthy, MBBS, MS, Christina Adams, CT(ASCP), Yener Erozan, MD. Pathology, The Johns Hopkins Medical Institutions, Baltimore, Maryland Introduction: Molecular testing for mutational status of Kirsten Rat Sarcoma (KRAS), Epidermal Growth Factor Receptor (EGFR) and Anaplastic Lymphoma Kinase (ALK) in lung adenocarcinoma is an integral component of clinical management. These mutations are thought to be mutually exclusive, such that they should be tested in an algorithmic manner. Since up to 70% of patients present at an inoperable stage, cytology and small biopsy specimens are increasingly used as the only source of tissue for testing and play a critical role in the selection of appropriate chemotherapeutic agents. Materials and Methods: A retrospective analysis of molecular testing for KRAS, EGFR and ALK mutations over a 5-year period in a large tertiary care center was performed. There were 168 cases of lung adenocarcinoma and non-small cell lung carcinoma that had undergone testing for one, two or all three mutations. All the testing was performed on cell block material from EBUS-guided, transthoracic (TT) or transbronchial (TBNA) needle aspirations, pleural fluids (PF) or FNAs from distant metastatic sites. Results: The distribution of specimens by diagnoses and procedure type is displayed in Table 1. There was insufficient material for KRAS/EGFR testing in 15/168 (8.9%) specimens (Table 1). Four of these cases had sufficient material for ALK testing. Nineteen cases had surgical specimens, 3 of which had molecular testing performed on them. Two of the three cases also had molecular testing performed on cytologic material. Test results by mutation are shown in Table 2. Eight cases that had a KRAS mutation had EGFR testing also performed, while in 34 such cases, EGFR testing was appropriately canceled subsequent to a positive KRAS mutation. Turn-around-time (TAT) for KRAS, EGFR and ALK testing was approximately 1 week-10 days, 2-2.5 weeks and 1 week respectively.
Specimens Adenocarcinoma NSCLC Insufficient (percentage)
EBUS-FNA
TT
TBNA
PF
Other
80 70 10 5 (6%)
12 12 0 2 (16%)
8 7 1 0
23 21 2 2 (8.6%)
45 42 3 6 (13%)
EBUS: Endobronchial ultrasound FNA: Fine needle aspiration TT: Transthoracic TBNA- Transbronchial needle aspiration PF: Pleural fluid Table 2
Distribution of test results by mutation
Test
KRAS
EGFR
ALK
Performed Positive Negative
129 44 87
131 14 83
44 3 41
Conclusions: Cytologic material can be efficiently used for molecular testing in lung adenocarcinomas. Specimens acquired by EBUS and transthoracic procedures have the lowest and highest rates of insufficient material for molecular tests respectively. There is a need for an effective Standard Operating Procedure to optimally utilize the limited cytologic material while keeping the TAT as short as possible. Availability of clinical information is critical so as to not perform redundant immunohistochemical/molecular tests in patients who have already been tested in outside facilities. An algorithmic approach and coordination with histology can avoid redundant in-house testing. 157 Rapid On-site Evaluation of Pulmonary Samples: Correlation between Cytology and Surgical Pathology Diagnoses of Non-small Cell Carcinoma
Introduction: Rapid on-site evaluation (ROSE) of pulmonary cytologic samples improves diagnostic yield in sampling of lung masses and mediastinal/hilar lymph nodes. In addition to confirmation of an adequate sample, ROSE allows triage of material for ancillary testing and facilitates communication between patient care teams. This should result in an increased ability to make a more specific cytologic diagnosis with definitive cell typing of non-small cell carcinoma. Our institution began ROSE of pulmonary cytologic specimens in 2008. The goal of this study is to assess the accuracy and completeness of cytologic diagnosis in comparison to final surgical diagnosis. Materials and Methods: Following Institutional Review Board approval, all cases with ROSE by a cytopathologist from 2008-2011 were extracted from the anatomic pathology database. All cases that included both a cytology specimen (FNA, brushing, washing) and a surgical biopsy or resection specimen with a positive (or suspicious) diagnosis of non-small cell carcinoma (NSCC) in the lung were included. Patient age, gender, final cytology and surgical pathology diagnoses, and use of immunostains were recorded in each case. Concordance of the cytologic and surgical diagnoses was determined as follows: Concordant - the same diagnosis was reached in both cytology and surgical specimens (ex. Adenocarcinoma, squamous cell carcinoma, or NSCC); partially concordant - A diagnosis of malignancy was made, but the cytology or surgical specimens were more or less specific (ex. NSCC on cytology and adenocarcinoma on biopsy). Results: In a three year time period, a total of 164 cases from 160 patients that had a positive (or suspicious) non-small cell carcinoma diagnosis on a cytology or surgical specimen were obtained. 85 (53%) patients were female and 77 (47%) were male. Their ages ranged from 26 to 89 years (median 68 years). Of the 164 cases, 154 had positive diagnoses and the remaining 11 were suspicious for carcinoma on the cytology or surgical specimens. In the cases that were definitively diagnostic, 97 (59%) were concordant and 16 (10%) were partially concordant. Of the concordant cases, 39 (40%) had immunostains done on the cytology or surgical specimen. Of the