Transbronchial Fine Needle Aspiration Research Articles

Aspergillus fumigatus: Is Dual-Tracer 18FDG/68Ga-FAPI PET/CT Capable of Distinguishing Fungal Infection and Unspecific Inflammation From Recurrent Lung Cancer?

A 61-year-old woman, referred for recurrent pneumonia over a period of 3 months with insufficient response to antibiotic treatment, presented with coughing and intense right-sided chest pain. Previously, she underwent right upper lobectomy for locally advanced non-small cell lung cancer (squamous cell carcinoma) followed by adjuvant chemotherapy and subsequent partial chest wall resection with polytetrafluoroethylene net insert due to a pleurocutaneous fistula. 18FDG plus a 68Ga-labeled fibroblast activation protein inhibitor (68Ga-FAPI) PET/CT scans were performed to rule out non-small cell lung cancer recurrence. Pathological workup with bronchoscopy and endobronchial ultrasound-guided transbronchial fine-needle aspiration of the lymph nodes showed no evidence of malignancy, but microbiology confirmed Aspergillus fumigatus infection of the middle lobe. Thus, the patient transitioned from antibiotic to antifungal therapy; no second-line oncologic treatment was initiated.

Endobronchial ultrasound-guided transbronchial fine needle aspiration of mediastinal lymphadenopathy: Diagnostic performance and clinical implications of the World Health Organization reporting system.

Lymph node fine-needle aspiration cytology (LN-FNAC) is a common, rapid, minimally invasive and cost-effective diagnostic method. For mediastinal lymph nodes, endobronchial ultrasound (EBUS) guided LN-FNAC is a first-line investigation and has an indispensable role in the diagnosis and staging of patients with suspected lung cancer. Recently, a new WHO system has been proposed for classification of LN-FNAC heralding five different diagnostic categories; insufficient, benign, atypical, suspicious for malignancy and malignant. The aim of this study was to evaluate the diagnostic accuracy and risk of malignancy (ROM) of these categories in EBUS-guided LN-FNAC from mediastinal lymph nodes. We evaluated 2110 consecutive mediastinal lymph nodes during this one-year retrospective study. Corresponding radiological images and histologic material were used as ground truth to calculate accuracy, sensitivity, specificity and ROM. The WHO system showed an overall accuracy of 93.7% with a sensitivity of 83.0% and a specificity of 97.5%. The positive predictive value was 92.3% and the negative predictive value 94.2%. The overall ROM for each category in the WHO classification system was 12.8% for the inadequate, 2.4% for the benign, 47.4% for the atypical, 81.0% for the suspicious for malignancy and 93.6% for the malignant category. The results of the present study indicate that the new WHO system entails a high diagnostic accuracy regarding EBUS-guided LN-FNAC assessment of mediastinal lymph nodes and supports its integration into clinical practice. Application of the WHO system standardizes risk assessment thus facilitating communication between cytopathologists and clinicians and minimizes the need for histopathological analysis.

A Review of Endobronchial-Ultrasound-Guided Transbronchial Intranodal Forceps Biopsy and Cryobiopsy.

Benign and malignant mediastinal lesions are not infrequently encountered in clinical practice. Mediastinoscopy has long been considered the gold standard in evaluating mediastinal pathology. Since its introduction into clinical practice, endobronchial-ultrasonography-guided transbronchial fine needle aspiration (EBUS-TBNA) has replaced mediastinoscopy as the initial procedure of choice to evaluate mediastinal lesions and to stage lung cancer. Its diagnostic yield in benign mediastinal lesions and less common malignancies, however, has remained limited. This has led different proceduralists to investigate additional procedures to improve the diagnostic yield of EBUS-TBNA. In recent years, different published reports concluded that the addition of EBUS-guided intranodal forceps biopsy (IFB) and transbronchial cryobiopsy (TBCB) to EBUS-TBNA increases the diagnostic yield especially in benign mediastinal lesions and uncommon mediastinal malignancies. The purpose of this review is to describe how EBUS-IFB and EBUS-TBCB are performed, to compare their diagnostic yields, and to discuss their limitations and their potential complications. In addition, the review will conclude with a proposed algorithm on how to incorporate EBUS-IFB and EBUS-TBCB into clinical practice.

Accuracy of endobronchial ultrasound (EBUS) in the staging of lung cancer - A comparison of staging EBUS with postoperative pathological nodal staging.

Endobronchial ultrasound-guided transbronchial fine-needle aspiration (EBUS-TBNA) has replaced mediastinoscopy as the preferred investigation for evaluating mediastinum in staging lung cancer. There is little evidence of mediastinal staging by EBUS-TBNA from India. To study endobronchial ultrasound's diagnostic accuracy in staging lung cancer. We retrospectively analysed patients operated on for lung cancer where EBUS was performed preoperatively for mediastinal staging. We compared the histological findings obtained from different mediastinal lymph nodes (LNs) by EBUS-TBNA with the pathology of the same LNs obtained after surgical dissection as the reference standard. Seventy-six patients underwent curative surgery for lung cancer. The diagnostic accuracy, sensitivity, specificity, positive predictive value and negative predictive value of EBUS-TBNA in predicting mediastinal metastasis were 93.9%, 40%, 99%, 80% and 94.6%, respectively. Of the 115 LNs sampled, EBUS-TBNA was false negative in six nodes, resulting in an up-staging of six patients. EBUS-TBNA has a high diagnostic accuracy for lung cancer staging.

Utility of rapid on-site evaluation (ROSE) using toluidine blue stain in respiratory cytology

Introduction and Aim: Cytology has gained importance as a diagnostic test in pulmonary lesions, especially in patients presenting with advanced malignancy which are surgically non-resectable. Although cytopathological diagnosis may be limited, its role cannot be underestimated considering the minimal invasive nature of the technique. Single slide (SS) Rapid on-site evaluation (ROSE) will aid in adequacy assessment and diagnosis of pulmonary lesions on cytopathology. Materials and Methods: We conducted a prospective study. SS ROSE was done on transbronchial fine needle aspiration and bronchial brushing specimens using toluidine blue staining. The slides were microscopically evaluated for adequacy and for diagnosis. In case of inadequate smears, a repeat was suggested. The diagnosis was compared with the diagnosis rendered on remaining slides which were processed using conventional cytology. Results: The study includes 82 cases for ROSE. A correlation of 100% was found between ROSE diagnosis and final cytology diagnosis. Out of 82 cases, 24 cases were malignancies and 3 were granulomatous lesions on ROSE. The remaining were negative for atypical/malignant cells. 2nd pass was advised in 21 cases due to the inadequacy of the diagnostic material in 1st pass. Out of 21 cases advised for 2nd pass, 11 were found to be malignant. A statistically significant p value of 0.05 was obtained. Conclusion: In our study, we found that ROSE using toluidine blue stain is simple, yet a very useful procedure to reduce the number of passes, the need for repeat bronchoscopy procedure and helpful in suggesting more samples for ancillary tests and rapid cytopathological diagnosis.

Evaluation of automated sample preparation system for lymph node sampling.

Endobronchial ultrasound-guided transbronchial fine needle aspiration (EBUS-FNA) has revolutionized the diagnostic and staging approach to non-small cell carcinoma and thoracic lymphadenopathy. However, obstacles to efficacy of rapid on-site evaluation (ROSE) of the samples include variability in sample quality and slow and cumbersome process in the procedure room leading to extended procedure time. The purpose of this pilot study was to evaluate the feasibility and specimen quality of lymph node biopsies prepared through a novel automated system for automated fixation, drying and staining compared to standard slide preparation method. We performed a prospective, single-center pilot feasibility study of patients undergoing EBUS. Samples were split into conventional standard of care (SOC) slide preparation and preparation using the device ("instrument"). Pathologists compared the SOC slides to the slides prepared by the automated system and assessed the following metrics: nuclear and cytoplasmic quality, presence of debris/artifact, staining quality, creation of a monolayer, and ease of adequacy/diagnosis assessment. A score between 1 (lowest quality) and 3 (highest quality) was assigned to the above metrics. Sixty patients were recruited. One to three lymph nodes were sampled for each patient for a total of 72 samples collected. The mean scores of each assessment category showed no statistical difference between the two preparation techniques except for improved monolayer creation in the instrument samples. Thirty of thirty-one (96.8%) paired samples in the final analysis showed diagnostic equivalency between the automated slides and conventional slides; the discordant pairing was reported to be suspicious on the instrument sample and atypical on the SOC. Study results suggest that slides prepared by the automated system are of adequate quality for adequacy assessment with diagnostic concordance when compared to SOC slides.

741 ACUTE PURULENT MYOPERICARDITIS SECONDARY TO ULTRASOUND-GUIDED TRANSBRONCHIAL NEEDLE ASPIRATION CYTOLOGY

Abstract Introduction Endobronchial ultrasound-guided transbronchial fine needle aspiration (EBUS-TBNA) is a minimally invasive diagnostic method to sample peritracheal and peribronchial le- sions under real-time ultrasound guidance. The most important use of TBNA is the diagnosis and staging of lung cancer and the evaluation of sarcoidosis. Although TBNA is considered generally safe, serious or even fatal complication may develop after the procedure. Here we present a case report of acute purulent myopericarditis complicated by cardiac tamponade occurred after EBUS-TBNA procedure. Case Report A 62-year-old man with preexisting hypertension and previous myocardial infarction and coronary angioplasty was admitted to our hospital for persistent, oppressive and worsening chest pain, which started a few days before admission. Of note, the patient underwent EBUS-TBNA 10 days before admission because he was found to have a tumor in the upper lobe of the left lung and enlargement of multiple mediastinal, right hilar, subcarinal and para-aortic lymph nodes. Two days after the procedure, one week before admission, he was treated with amoxicillin clavulanate and levofloxacin because of fever onset. At the ER, his vital signs showed a blood pressure of 80/60 mmHg and a heart rate of 115 bpm; O2 saturation on room-temperature air was 97%. The ECG at presentation showed concave ST segment elevation in anterolateral and inferior leads. The echocardiography revealed moderate circumferential pericardial effusion without clear tamponade signs. Emergency coronary angiography showed patent coronary arteries. The next morning, the patient developed persistent hypotension (BP 75/50 mmHg). A transthoracic echo showed moderate to large circumferential pericardial effusion with tamponade physiology. He therefore underwent subxiphoid pericardiotomy with drainage of 400 ml of frank pus. Cultures from pericardial fluid were negative for common germs. Cytology was negative for malignancy and acid-fast bacilli. Histological examination of the pericardial tissue was diagnostic for acute fibrinous-purulent pericarditis. The patient was started on broad spectrum antibiotics (piperacillin/tazobactam and ciprofloxacin) with subsequent decrease of inflammation markers and clinical improvement. Control contrast enhanced chest CT scan revealed persistency of a mediastinal pluri-concamerate fluid collection. After a collective discussion with cardiac surgeons, infectious disease specialists and oncologists, given the progressive clinical and instrumental improvement, we decided to discharge the patient with long term oral antibiotics plus colchicine and ibuprofen for pericarditis. Infectious disease and oncological follow up was planned before discharge. Conclusion Complications following TBNA are relatively low, typically around 1.2%-1.4%. To date, only few cases of purulent pericarditis secondary to EBUS-TBNA have been reported in literature. Our case report adds to the existing scant literature regarding cardiac infective bronchoscopic complications and emphasizes concern of weather antibiotic prophylaxis may be needed before respiratory tract invasive procedures. Further research is necessary to better understand the existence of risk factors that could increase the probability to develop such rare but potentially lethal complications.

LIFE-THREATENING HEMOPTYSIS AS A COMPLICATION OF ENDOBRONCHIAL ULTRASOUND-GUIDED NEEDLE ASPIRATION IN A 55-YEAR-OLD MAN WITH END-STAGE RENAL DISEASE

LIFE-THREATENING HEMOPTYSIS AS A COMPLICATION OF ENDOBRONCHIAL ULTRASOUND-GUIDED NEEDLE ASPIRATION IN A 55-YEAR-OLD MAN WITH END-STAGE RENAL DISEASE

AN ALTERNATE APPROACH: TRANSESOPHAGEAL BRONCHOSCOPIC ULTRASOUND-GUIDED FINE NEEDLE ASPIRATION (EUS-B-FNA) TO ASSESS PLEURAL MESOTHELIOMA

AN ALTERNATE APPROACH: TRANSESOPHAGEAL BRONCHOSCOPIC ULTRASOUND-GUIDED FINE NEEDLE ASPIRATION (EUS-B-FNA) TO ASSESS PLEURAL MESOTHELIOMA

Mediastinal ve hiler lenfadenopatilerde endobronşiyal ultrason eşliğinde kullanılan power Doppler modunun benign ve malign lenf nodu ayırımına katkısı

Aim: The aim of this study was to investigate the contribution of power Doppler mode used in the differentiation of malignant and benign lymph nodes in patients with mediastinal and hilar lymphadenopathies undergoing diagnostic fine needle aspiration under the guidance of convex probe endoscopic ultrasound (EBUS).Material and Methods: Medical files of patients who underwent EBUS between March 2018 and February 2019 were retrospectively analyzed. A total of 143 lymph nodes of 85 patients were included in the study. The demographic characteristics of the patients with a definite diagnosis and EBUS radiological and sonographic characteristics of the sampled lymph nodes were recorded. As a result of the evaluation of mediastinal lymph nodes with EBUS, the sensitivity, specificity, negative and positive predictive values were calculated for power Doppler mode in the detection of malignant lymph nodes.Results: Of a total of 85 patients, 62 (73%) were males and 23 (27%) were females with a mean age of 62±10.4 (range, 37 to 80) years. In the vascular pattern evaluation, 87 (60.8%) lymph nodes were negative and 56 (39.2%) were positive for malignancy. Comparing final diagnoses and vascular pattern analysis results revealed a statistically significant difference between benign and malignant lymph nodes in favor of power Doppler mode under the guidance of EBUS (p <0.01).Conclusion: Convex probe EBUS can identify the first lymph node to be sampled based on sonographic characteristics of lymph nodes and allow simultaneous imaging and transbronchial fine needle aspiration procedures. Therefore, it may shorten the procedural time and reduce the amount of anesthesia to be used.

Pediatric Sarcoidosis: A Review with Emphasis on Early Onset and High-Risk Sarcoidosis and Diagnostic Challenges.

Sarcoidosis is a non-necrotizing granulomatous inflammatory syndrome with multisystemic manifestations. We performed a systematic review of sarcoidosis in the pediatric population with particular emphases on early onset sarcoidosis, high-risk sarcoidosis, and newly reported or unusual sarcoid-related diseases. Blau Syndrome and early onset sarcoidosis/ BS-EOS are seen in children younger than five years old presenting with extra-thoracic manifestations but usually without lymphadenopathy and/or pulmonary involvement. The prevalence of high-risk sarcoidosis is very low in children and is further limited by the difficulty of diagnosis in symptomatic children and underdiagnosis in subclinical or asymptomatic patients. Reports of sarcoidal syndromes in users of E-cigarette/marijuana/other flavorings and their induction in cancer immunotherapies are of interests and may be challenging to differentiate from metastatic malignancy. The diagnostic considerations in pediatric sarcoidosis are to support a compatible clinicoradiographic presentation and the pathologic findings of non-necrotizing granulomas by ruling out granulomas of infective etiology. There is no absolutely reliable diagnostic test for sarcoidosis at present. The use of endoscopic bronchial ultrasound (EBUS) and transbronchial fine needle aspiration (TBNA) sampling of intrathoracic lymph nodes and lung, and for superficially accessible lesions, with cytopathological assessment and pathological confirmations provide fair diagnostic yield and excellent patient safety profile in children.

A CASE OF LEUKEMIA COMPLICATED BY NON-SMALL CELL LUNG CANCER

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: The occurrence of multiple primary cancers (MPCs) is rare. The diagnosis and treatment of MPCs is often challenging, and often, they cannot be treated simultaneously (1). We report a case of a patient with recurrent pre-B-cell acute lymphoblastic leukemia (pBALL) who was diagnosed with a new non-small cell lung carcinoma (NSCLC). CASE PRESENTATION: A 51 year old male with a remote history of testicular cancer s/p orchiectomy and cisplatin and recurrent pBALL presented with a 4 day history of shortness of breath, non-productive cough and fatigue. Twelve months prior, he was diagnosed with pBALL and treated with 1 cycle of cytarabine, dexamethasone, vincristine, daunorubicin, pegasparagasen and intrathecal methotrexate, and 4 cycles of cyclophosphamide, vincristine, doxorubicin, and dexamethasone, which he completed 2 months prior to presentation. A CT angiogram showed a 2.4 cm right parahilar mass (Figure 1). Bronchoscopy revealed an endobronchial lesion in the right upper lobe (Figure 2) and fine needle aspiration was performed. Endobronchial ultrasound was employed to perform transbronchial fine needle aspiration of station 11R (Figure 2). Immunohistochemistry showed positive staining for CK5/6 and CKAE1/3. P53 staining was also strongly positive in the malignant cells (Figure 3). These staining patterns supported a diagnosis of NSCLC. The patient was readmitted shortly after with recurrence of his pBALL. Unfortunately, given disease progression on imaging and by symptoms, the patient opted for hospice care. DISCUSSION: The prevalence of MPCs is uncertain, ranging between 0.734-11.7%(2). While MPCs are uncommon in general, the combination of hematologic and solid cancers is rare. The SEER database suggests a slight increased occurrence of lung cancer in patients with ALL compared to the general population (3). The etiology is not clear. The few cases that have been published highlight the association between hematologic cancers treated with various chemotherapy regimens and the development of subsequent solid tumors, or a possible hereditary component (1,3). CONCLUSIONS: Although it may seem redundant to biopsy a new lesion identified in a patient with malignancy, it is important that clinicians consider the possibility of MPCs in certain clinical contexts as they can complicate primary disease treatment and may limit treatment options of the new disease. Reference #1: Cui Y, Liu T, Zhou Y, et al. “Five cases report of solid tumor synchronously with hematologic malignancy.” Cancer Res Treat. 2012 Mar;44(1):63-8. https://doi.org/10.4143/crt.2012.44.1.63. Epub 2012 Mar 31. Reference #2: Demandante CG, Troyer DA, Miles TP. “Multiple primary malignant neoplasms: case report and a comprehensive review of the literature.” Am J Clin Oncol. 2003 Feb;26(1):79-83. Review. Reference #3: Shah, B. K. (2013). Second Primary Malignancies In Adult Acute Lymphoblastic Leukemia. Blood, 122(21), 3871. Accessed March 14, 2019. Retrieved from http://www.bloodjournal.org/content/122/21/3871. DISCLOSURES: No relevant relationships by Erum Arain, source=Web Response No relevant relationships by Amit Goyal, source=Web Response No relevant relationships by Michal Reid, source=Web Response

The Improvement of Diagnostic Accuracy Using Touch Preparation Combined with Biopsy and Transbronchial Fine Needle Aspiration in Rapid Onsite Evaluation in Lung Mass

The Improvement of Diagnostic Accuracy Using Touch Preparation Combined with Biopsy and Transbronchial Fine Needle Aspiration in Rapid Onsite Evaluation in Lung Mass

Role of Endobronchial Ultrasound in Diagnosis of Mediastinal and Pulmonary Lesions

AbstractBackground: Lung cancer is one of the most common tumors worldwide. Now it ranks as the leading cause of cancer related death in the world, both in men and women. Pulmonary lesions detected during screening for lung cancer need to be evaluated further and tissue should be obtained. Technical development in last two decades has made it possible for pulmonologists to do endobronchial ultrasound “EBUS”.Aim of Study: The aim of the work is Assessment of the role of endobronchial ultrasound TBNA in diagnosis of me-diastinal lesions as accurate rapid less invasive procedure.Subjects and Methods: This is a Prospective study was conducted on 30 patients presented with chest symptoms (dyspnea, cough, expectoration, chest pain and hemoptysis) diagnosed as mediastinal, hilar and pulmonary lesions as confirmed by CT chest, routine labs and proper history taking and through clinical examination and underwent EBUS-TBNA and the sampled lesion was sent for histopathological exam-ination and reporting at Kobbry Al-Kobba Military Hospital during the period from (November 2015 to October 2016).Results: The mean age of the patients participating in this study was 44.9±15.9 years (ranges 17–73). 56.7% of them were males while 43.3% were femles. Radiological finding showed Hilar & mediastinal lymphadenopathy in 40.0%, mediastinal lymphadenopathy (6.7%), hilar lymphadenopathy (10.0%), pulmonary lesions (33.3%), pulmonary lesions with mediastinal lymphadenopathy (6.7%), pulmonary lesions with mediastinal and hilar lymphadenopathy (3.3%). EBUS findings were 20 patients were having lymph node lesions (85% were benign and 15% were malignant by pathology) and 10 patients were having mass lesions (100% were malignant). No com-plications were detected only minor hemorrhage in 1 patients (3.3%).Conclusion: Endobronchial ultrasound guided transbron-chial fine needle aspiration EBUS-TBNA is the procedure of choice for staging of lung cancers and for the investigation of unexplained mediastinal lymphadenopathy and masses. EBUS guided TBNA is an accurate, cost effective and mini-mally invasive procedure and if successfully performed, TBNA may spare patients additional, more invasive procedures or surgery.

Committee II: Guidelines for cytologic sampling techniques of lung and mediastinal lymph nodes.

The Papanicolaou Society of Cytopathology has developed a set of guidelines for pulmonary cytology including indications for bronchial brushings, washings, and endobronchial ultrasound guided transbronchial fine-needle aspiration (EBUS-TBNA), technical recommendations for cytological sampling, recommended terminology and classification schemes, recommendations for ancillary testing and recommendations for post-cytological management and follow-up. All recommendations are based on the expertise of the authors, an extensive literature review and feedback from presentations at national and international conferences. This document selectively presents the results of these discussions. The present document summarizes recommendations regarding techniques used to obtain cytological and small histologic specimens from the lung and mediastinal lymph nodes including rapid on-site evaluation (ROSE), and the triage of specimens for immunocytochemical and molecular studies.

Biopsy Site Changes in Resected Mediastinal Lymph Nodes with Prior Endobronchial Ultrasound-Guided Transbronchial Fine Needle Aspiration (EBUS-TBNA)

Biopsy Site Changes in Resected Mediastinal Lymph Nodes with Prior Endobronchial Ultrasound-Guided Transbronchial Fine Needle Aspiration (EBUS-TBNA)

Endobronchial ultrasound-guided transbronchial fine needle aspiration: Determinants of adequacy.

This study aims to evaluate the factors influencing the adequacy of endobronchial ultrasound-guided transbronchial fine needle aspiration specimens. A retrospective analysis of 1,700 endobronchial ultrasound-guided transbronchial fine needle aspiration samples obtained from 822 patients (500 males, 322 females; mean age 56±13 years; range 16 to 83 years) was performed between March 2011 and March 2014 at our center. Variables potentially associated with sampling adequacy, such as all cytological materials and procedure notes (lymph node and/or lesion size, localization, needle pass number, and slide number) were examined. The overall specimen adequacy was 79.8%. The specimen adequacy was associated with needle pass number (p≤0.001). Adequacy rate was 66.9% for one needle pass and 85.8% for three needle passes. According to the sampling regions, adequacy rates showed a difference [69.2%-85.8%; (p≤0.005)]. In the multivariate logistic regression analysis of subcarinal (7) lymph node station, patient age (odds ratio, 0.983; 95% confidence interval, 0.966-1.000; p=0.049) and number of slides (odds ratio, 1.240; 95% confidence interval, 1.062-1.448; p=0.006) were independent determining factors of specimen adequacy. While independent determinants of specimen adequacy for the right paratracheal (4R) region were lymph node size (odds ratio, 1.486; 95% confidence interval, 0.973-2.268; p=0.067) and number of slides (odds ratio, 1.418; 95% confidence interval, 1.146-1.756; p=0.001), they were lymph node size (odds ratio, 1.594; 95% confidence interval, 0.960-2.645; p=0.071) and number of needle passes (odds ratio, 2.277; 95% confidence interval, 1.360-3.811; p=0.002) for the right interlobar (11R) region. Independent determinant of specimen adequacy for the left paratracheal (4L) lymph node station was the number of needle passes (odds ratio, 1.656; 95% confidence interval, 0.955-2.869; p=0.072). During endobronchial ultrasound-guided transbronchial fine needle aspirations, particularly when rapid on site evaluation cannot be applied, consideration of factors affecting adequacy according to lymph node localizations may increase the chance for obtaining materials with suitable quality for cytologic evaluation.

Molecular Testing of Non-Small Cell Lung Carcinoma Diagnosed by Endobronchial Ultrasound-Guided Transbronchial Fine-Needle Aspiration: The Cleveland Clinic Experience.

Given the increasing demand for molecular testing of non-small cell lung carcinoma specimens to guide therapeutic decision-making and the trend toward minimally invasive techniques for obtaining diagnostic tissue, cytopathology laboratories must devise strategies to maximize DNA yield for necessary molecular testing. To describe our experience at Cleveland Clinic with epidermal growth factor receptor (EGFR) mutation testing by next-generation sequencing and anaplastic lymphoma kinase (ALK) gene rearrangement testing by fluorescence in situ hybridization of non-small cell lung carcinomas diagnosed by cytology, with an emphasis on specimens obtained by endobronchial ultrasound-guided transbronchial fine-needle aspiration. Data sources include a review of the current literature, including published articles from our institution. At our institution, liquid-based cytology specimens are the primary resource used for molecular testing of non-small cell lung carcinomas; in most instances, adequate DNA can be extracted from the residual cell pellet for next-generation sequencing, and ThinPrep slides can be used reliably for fluorescence in situ hybridization testing for ALK gene rearrangements. In occasional cases where the cell pellet material is not adequate for molecular testing, cell blocks and/or surgical pathology specimens are secondary options. The cytopathologist's role in specimen handling and triage is essential to ensure that molecular testing can be carried out successfully.

BRAF Mutated Tall Cell Papillary Carcinoma Lung Metastasis Following Thyroidectomy

SESSION TITLE: Metastatic and Other Primary Lung Tumors SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: BRAF Mutated Tall Cell Papillary Carcinoma is a rare tumor infrequently presented as lung metastasis. Although Papillary Carcinoma is one of the most frequent Thyroid Cancers, BRAF-Tall Cell Variant carries the worst prognosis. CASE PRESENTATION: A 65-year-old male former 12-pack year smoking history and total thyroidectomy as a child presents for evaluation of hematochezia. He has no prior history of radiation exposure or familial history of thyroid cancer. Supplemental thyroid replacement therapy was started at age 21 due to clinical hypothyroidism. Residual thyroid glandular tissue was not visible on CT scan or ultrasound studies. Abdominal and pelvic computed tomography (CT) scan demonstrated the incidental finding of a 1.2 cm non-calcified lobulated and speculated pulmonary nodule. Positron Emission Test (PET) Scan demonstrated maximum SUV uptake of 11.0 in mediastinal and pretracheal structures. Mediastinoscopy aborted after experiencing intraoperative bleeding complications. Endobronchial Ultrasound Trans-bronchial fine needle aspiration (EBUS-TB FNA) was was non-diagnostic. Exploratory thoracotomy with right middle lobe wedge resection and mediastinal lymph node dissection was performed. Surgical biopsy diagnosed a poorly differentiated tall cell papillary carcinoma, BRAF positive mutation. DISCUSSION: BRAF is a important oncoprotein responsibile for the MAPK-pathway output. Its role suppresses the expression of genes required for iodide incorporation. Due to poor iodide uptake, radioactive iodine is not useful diagnostically or therapeutically in tall cell variant disease. CONCLUSIONS: BRAF-mutated classical or tall-cell-variant papillary thyroid carcinomas have a high frequency of lymph-node metastases and recurrence after thyroidectomy. These associated carcinomas have a poor response to radioiodine therapy due to the high MAPK-pathway output, which is driven by the BRAF V600E oncoprotein. This case demonstrates the difficulty with diagnosis of mediastinal lymphadenopathy and rare presentation of tall cell variant papillary cell carcinoma as lung metastasis. Reference #1: American Cancer Society: Cancer Facts and Figures 2016. Atlanta, Ga: American Cancer Society, 2016. Reference #2: Gimm, O., Rath, F. W. and Dralle, H. (1998), Pattern of lymph node metastases in papillary thyroid carcinoma. Br J Surg, 85: 252-254. doi:10.1046/j.1365-2168.1998.00510.x Reference #3: Xing M, Westra WH, Tufano RP, et al. BRAF mutation predicts a poorer clinical prognosis for papillary thyroid cancer. J Clin Endocrinol Metab 2005;90:6373-9. DISCLOSURE: The following authors have nothing to disclose: Brandon Hooks No Product/Research Disclosure Information

Primary Salivary Gland Tumors of the Tracheobronchial Tree Diagnosed by Transbronchial Fine Needle Aspiration: Clinical and Cytomorphologic Features with Histopathologic Correlation

Primary Salivary Gland Tumors of the Tracheobronchial Tree Diagnosed by Transbronchial Fine Needle Aspiration: Clinical and Cytomorphologic Features with Histopathologic Correlation