Walid Khalbuss
VMT2
Current Diagnostic Challenges in Lung FNA Walid E Khalbuss, MD PhD FIAC Professor of Pathology & Director of Cytology University of Pittsburgh Medical Center (UPMC)
[email protected]
Speaker Disclosure In the past 12 months, months I have not had a significant financial interest or other relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) that will be disc ssed in my discussed m presentation. presentation
Walid Khalbuss
Diagnosis of Lung Cancer in Small Biopsies and Cytology Implications of the 2011 International Association for the Study of Lung Cancer/ American Thoracic Society/European Respiratory Society Classification. Travis et al, Arch Pathol Lab Med. 2012;136:1–17.
Yoshizawa et al, 2011
Do more with less tissue NSCLC & EBUS/EUS FNA Common & Important Dx
70% of f NSCLCs NSCLC are unrespectable t bl att presentation t ti many Dx’s made based on cytology Evaluation: morphology, IHC, molecular
Important to subtype for selection of appropriate treatment
Sigel CS et al, J Thorac Oncol 2011
S b l ifi i of Sub-classification f NSCLC Cytology superior for morphology & subclassification
Better nuclear & cytoplasmic detail Less fixation artifact
Morphology
AdenoCa: prominent nucleoli, vacuolated cytoplasm; glands and strips on CB SqCC: dense cytoplasm cytoplasm, more pleomorphism, pleomorphism coarse chromatin; 2D syncytial groups with keratin pearls and intercellular bridges
Sigel CS et al, J Thorac Oncol 2011
Sub-Classification of NSCLC • Accurate sub-classification of NSCLC and acquisition of sufficient material for molecular studies is crucial. • Balancing the need of adequate material for accurate diagnosis with the demands of clinicians to do more with less tissue has been a challenge and continues to impact the way lung cancers are approached in cytopathology.
Comparison of lung diagnosis in the past and i cytomorphology t h l presentt using Treatment g Surgical: NSCLC Non-surgical: SCC
•
•
Need for subtyping and molecular studies Theranostic data Monaco, 2012
IHC
NSCLC FNA
AdenoCa: +CK7, +CK7 +TTF1 (+NapsinA) SqCC: +p63/p40 (+Glypican3, +CK5/6) Other: Synaptophysin p40
TTF1-Napsin A
TTF1
p40-CK5
p40-CK5
Molecular Testing g in NSCLC FNA Cases EGFR sequencing KRAS sequencing BRAF sequencing FISH for ALK FISH for FGFR1
Monaco, 2012
Conserving Tissue in Lung Ca Cases 26 Unstained slides on char charged ed slides Number slides in order when cutting Triage Blank #
Triage
1
H&E to case p pathologist g
2
H&E to FISH & Molecular Labs
3, 4, 5 6
First 3 IHC markers
(i.e. TTF-1, CK5/6 or p63/p40)
H&E to t case pathologist th l i t (deeper (d llevel) l)
7-15
Blanks to Molecular Lab
16-21
Blanks to FISH Lab
22-25
Blanks for additional testing (e.g. additional IHC)
26
Negative control for IHC
EBUS: +NSCLC 2 extra passes for cell block
S Squamous C Cell ll Carcinoma C i • • • • • • • • • • • • • • • • • • • •
More central (67%), males >50 yrs, now upper lobes. A geographic hi Sheets Sh t (2 (2-D); D) or single i l large l cells ll Pleomorphic cells, bizarre cells, Variable Keratinization (deep cytoplasmic orangophilia, or yellow/degenerative). Cytoplasmic rings (Herxheimer spirals), thickness with refractivity. Intercellular bridges (cell block better); gaps between cells Poorly differentiated have high N/C ratio and less or no keratinization Dense cytoplasm/glassy appearance/ cytoplasmic endocytoplasmic ringing p well defined cytoplasmic p borders. Sharp Can have cytoplasmic vacuolization. Peripheral and/or central nuclear spindling is usually appreciated. The nuclei tend to be central, hyperchromatic, pleomorphic and smudgy. n rma c coarse ar chr chromatin mat n clumping, c ump ng, para para-chromatin chr mat n clearing. c ar ng. Abnormal Small or macro-nucleolie. In high grade (non keratinizing ca), nuclei are more vesicular. Tadpole cell shapes (with other features of malignancies) Ghost cells Necrotic or inflammatory or rarely tigroid background Sometimes impossible to sub-classify PD squamous ca without immuno (CK5/6+, p40+,TTF1-) 84% are EGFR positive; KRAS, very rare
Squamous q Cell Carcinoma- Challenges g • Well-preserved malignant cells may be difficult • Single cells exhibiting squamous differentiation. • Syncytial tissue fragments without any architectural patterns. • Very pleomorphic dyskeratoic squamous cells. • Papillary or verrucous type, basaloid; Small cell, and clear cell variant • Small degenerating squamous cells aka pap cells.
Squamous Cell Ca- Grade/Subtype
Papillary variant
Squamous Papilloma
Well-differentiated
Moderately-differentiated
1.Squamous Papilloma
2. Keratinizing Squamous Ca
basaloid variant
Poorly-differentiated
3. Non-Keratinizing Squamous Ca
4. Clear cell Variant
5. Basaloid Variant
Acinar
Papillary
Micropapillary
Solid
Adenocarcinoma in Situ (
Current Diagnostic Challenges in Lung FNA Walid E Khalbuss, MD PhD FIAC Professor of Pathology & Director of Cytology University of Pittsburgh Medical Center (UPMC)
[email protected]
Speaker Disclosure In the past 12 months, months I have not had a significant financial interest or other relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) that will be disc ssed in my discussed m presentation. presentation
Walid Khalbuss
Diagnosis of Lung Cancer in Small Biopsies and Cytology Implications of the 2011 International Association for the Study of Lung Cancer/ American Thoracic Society/European Respiratory Society Classification. Travis et al, Arch Pathol Lab Med. 2012;136:1–17.
Yoshizawa et al, 2011
Do more with less tissue NSCLC & EBUS/EUS FNA Common & Important Dx
70% of f NSCLCs NSCLC are unrespectable t bl att presentation t ti many Dx’s made based on cytology Evaluation: morphology, IHC, molecular
Important to subtype for selection of appropriate treatment
Sigel CS et al, J Thorac Oncol 2011
S b l ifi i of Sub-classification f NSCLC Cytology superior for morphology & subclassification
Better nuclear & cytoplasmic detail Less fixation artifact
Morphology
AdenoCa: prominent nucleoli, vacuolated cytoplasm; glands and strips on CB SqCC: dense cytoplasm cytoplasm, more pleomorphism, pleomorphism coarse chromatin; 2D syncytial groups with keratin pearls and intercellular bridges
Sigel CS et al, J Thorac Oncol 2011
Sub-Classification of NSCLC • Accurate sub-classification of NSCLC and acquisition of sufficient material for molecular studies is crucial. • Balancing the need of adequate material for accurate diagnosis with the demands of clinicians to do more with less tissue has been a challenge and continues to impact the way lung cancers are approached in cytopathology.
Comparison of lung diagnosis in the past and i cytomorphology t h l presentt using Treatment g Surgical: NSCLC Non-surgical: SCC
•
•
Need for subtyping and molecular studies Theranostic data Monaco, 2012
IHC
NSCLC FNA
AdenoCa: +CK7, +CK7 +TTF1 (+NapsinA) SqCC: +p63/p40 (+Glypican3, +CK5/6) Other: Synaptophysin p40
TTF1-Napsin A
TTF1
p40-CK5
p40-CK5
Molecular Testing g in NSCLC FNA Cases EGFR sequencing KRAS sequencing BRAF sequencing FISH for ALK FISH for FGFR1
Monaco, 2012
Conserving Tissue in Lung Ca Cases 26 Unstained slides on char charged ed slides Number slides in order when cutting Triage Blank #
Triage
1
H&E to case p pathologist g
2
H&E to FISH & Molecular Labs
3, 4, 5 6
First 3 IHC markers
(i.e. TTF-1, CK5/6 or p63/p40)
H&E to t case pathologist th l i t (deeper (d llevel) l)
7-15
Blanks to Molecular Lab
16-21
Blanks to FISH Lab
22-25
Blanks for additional testing (e.g. additional IHC)
26
Negative control for IHC
EBUS: +NSCLC 2 extra passes for cell block
S Squamous C Cell ll Carcinoma C i • • • • • • • • • • • • • • • • • • • •
More central (67%), males >50 yrs, now upper lobes. A geographic hi Sheets Sh t (2 (2-D); D) or single i l large l cells ll Pleomorphic cells, bizarre cells, Variable Keratinization (deep cytoplasmic orangophilia, or yellow/degenerative). Cytoplasmic rings (Herxheimer spirals), thickness with refractivity. Intercellular bridges (cell block better); gaps between cells Poorly differentiated have high N/C ratio and less or no keratinization Dense cytoplasm/glassy appearance/ cytoplasmic endocytoplasmic ringing p well defined cytoplasmic p borders. Sharp Can have cytoplasmic vacuolization. Peripheral and/or central nuclear spindling is usually appreciated. The nuclei tend to be central, hyperchromatic, pleomorphic and smudgy. n rma c coarse ar chr chromatin mat n clumping, c ump ng, para para-chromatin chr mat n clearing. c ar ng. Abnormal Small or macro-nucleolie. In high grade (non keratinizing ca), nuclei are more vesicular. Tadpole cell shapes (with other features of malignancies) Ghost cells Necrotic or inflammatory or rarely tigroid background Sometimes impossible to sub-classify PD squamous ca without immuno (CK5/6+, p40+,TTF1-) 84% are EGFR positive; KRAS, very rare
Squamous q Cell Carcinoma- Challenges g • Well-preserved malignant cells may be difficult • Single cells exhibiting squamous differentiation. • Syncytial tissue fragments without any architectural patterns. • Very pleomorphic dyskeratoic squamous cells. • Papillary or verrucous type, basaloid; Small cell, and clear cell variant • Small degenerating squamous cells aka pap cells.
Squamous Cell Ca- Grade/Subtype
Papillary variant
Squamous Papilloma
Well-differentiated
Moderately-differentiated
1.Squamous Papilloma
2. Keratinizing Squamous Ca
basaloid variant
Poorly-differentiated
3. Non-Keratinizing Squamous Ca
4. Clear cell Variant
5. Basaloid Variant
Acinar
Papillary
Micropapillary
Solid
Adenocarcinoma in Situ (
