A short primer on

Exfoliative respiratory cytology

September 2007
 Acquisition of specimens
• Sputum
• BAL / Bronchial wash
• Bronchial brush
• Pleural fluid
• Needle biopsy
– Transbronchial
– Transesophogeal
– Transaortic
• Transthoracic FNA
 Sputum
• Accuracy
– Patient is spontaneously producing sputum
– Vigorous sampling (3-5 early morning specimens)
– Preservation techniques
– Location and size of tumor
• Central (SCLC, SCC)
– Sensitivity:
• Sens 0.66, Spec 0.99 (average 16 studies)
• Prebronchoscopy
– suspected Lung Ca: sens 0.10-0.74 (8 studies)
• Central sens 0.71, Peripheral sens 0.49 (17 studies)
 Sputum adequacy
• Numerous alveolar macrophages
• Patients with abnormal sputum cytology
should undergo bronchoscopy...
• Cells of bronchial cytology are
– Better preserved
– More numerous
– More cohesive
– Larger
– Lesions can be localized
– Cleaner background
 Bronchoalveolar lavage
• Useful for
– Peripheral lesions
– Severe diffuse disease
– Evidence of inoperability
– Diagnosis of opportunisitc infections
– Interstitial lung disease
– Evaluation of transplant rejection
 Evaluation
• Adequacy: bronchial cells,
abundant macrophages
• Keep your eyes peeled
for:
– Fungus
– Pneumocystis
– Viral inclusions
– Hemosiderin-laden
macrophages
– Atypical or malignant cells
 Cues
• Lymphocytes
– Sarcoid
– Hypersensitivity pneumonia
• Drug reaction
• Neutrophils / Macrophages
– Idiopathic pulmonary fibrosis
– Cytotoxic drug reaction
– Langerhans histiocytosis
• Hemosiderin laden macrophages
– Occult pulmonary hemorrhage (not acute phase)
– Also associated with infection
Bronchial wash cells Bronchial brush cells
Glandular cells

• Ciliated columnar cells

• Terminal bar
• Nuclei
– Basal oriented
– Round to oval
– Nuclear membrane smooth
• Chromatin
– Can appear hyperchromatic and coarse
– Regularly distributed
 Also
• Squamous cells • Clara cells
– Similar to gyn pap – Nonciliated bronchiolar cells
– Mostly superficial • Pneumocytes
• Goblet cells • Macrophages
– Basally oriented nucleus and – Bean nuclei
mucus
– Salt and pepper chromatin
– Usually one for every 5-10
ciliated cells – Carbon histiocytes
– Abundant, finely vacuolated – Siderophages
cytoplasm filled with mucus – Lipophages
– Abundant in asthma, – Muciphages
bronchitis, bronchiectasis,
and allergies
 Nonspecific findings
• Reserve cells
– Small round lymphocyte like
– Central, hyperchromatic nuclei
• Bronchial irritation cells
• Reactive atypia
• Multinucleation
• Regenerative/Reparative
• Ciliocytophthoria (ciliated tufts)
 Other findings
• Ferruginous (asbestos) bodies
• Elastin fibers
• Charcot-Leyden crystals
• Alveolar proteinosis
– Grossly opaque fluid, background of debris
• Corpora amylacea-
– Related to pulmonary edema
• Calcospherites and Psammoma bodies
• Contaminants (talc, pollen, plant/food cells)
 Diagnosis of lung cancer
• Suspicion based on abnormal radiologic
findings or local or systemic effects
• Diagnosis depends on
– Type (NSC vs SC)
– Size and Location
– Presence or absence of metastasis
– Clinical status of patient
• Maximize sensitivity
• Avoid multiple invasive or unnecessary
procedures.
 Small cell versus non-small cell
• Massive lymphadenopathy • Diagnostic method based
• Direct mediastinal invasion on presumed stage
– Mass in or adjacent to • Thoracentesis if pleural
hilum in 78% of cases effusion
• Paraneoplastic syndromes • FNA of metastatic site
– SIADH
– Ectopic ACTH
– Lambert-Eaton syndrome

Diagnosis by easiest means:

Sputum → thoracentesis → FNA of node or met →
bronchoscopy with or without TBNA.
 Case of suspicious lesion
• Biopsy versus resection
• Excisional biopsy is more sensitive
• No role for TTNA in early stage disease or
in surgical candidates
 References:
• Diagnosis of Lung Cancer: The Guidelines. M. Patricia Rivera,
Frank Detterbeck and Atul C. Mehta. Chest 2003;123;129-136.
DOI 10.1378/chest.123.1_suppl.129S.
• The Art and Science of Cytopathology. Demay. Exfoliative
respiratory cytology.
• Uptodate. Basic principles and technique of bronchoalveolar
lavage.
• Bronchoscopy International: Art of Bronchoscopy, an Electronic
On-Line Multimedia Slide Presentation.
http://www.Bronchoscopy.org/Art of Bronchoscopy/htm.
Published 2005 (Accessed 9/11/2007).
• www.cytologystuff.com
• Thanks to www.openoffice.org for allowing me to complete my
presentation when Powerpoint didn’t work.