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Houston, TX
Dr. Zander is Professor and Vice Chair of the Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at Houston Medical School.
Correspondence to: Dani S. Zander, MD, Professor and Vice Chair, Director of Anatomic Pathology, Harvey S. Rosenberg Chair in Pathology and Laboratory Medicine, University of Texas Health Science Center at Houston Medical School, Department of Pathology and Laboratory Medicine, 6431 Fannin, MSB 2.258, Houston, TX 77030; e-mail: dani.s.zander{at}uth.tmc.edu
In this issue of CHEST (see page 738), the article by Chandan and colleagues offers a look at the utility of core roll preparations (CRPs) for the immediate assessment of neoplastic lung lesions. For those who have not heard the phrase core roll preparation before, it is used by the authors to refer to a type of imprint cytology sample that can be obtained from core needle biopsy specimens. Essentially, the core needle biopsy sample is transferred to and lightly rolled on a glass slide, to produce a cellular preparation that can be rapidly air-dried, stained, and reviewed by the pathologist to provide feedback about lesional representation and, often, diagnosis. The authors retrospectively reviewed stained slides from fine-needle aspiration (FNA) and core needle biopsy/CRP samples collected from the same patient during the same visit, and have reported that a specific malignant cell type could be determined for 23 of 25 patients (92%). This result was superior to those they obtained from FNAs alone or CRPs alone, both of which usually provided a malignant diagnosis but often were not conclusive, alone, for the determination of a specific histologic tumor type. Whether the results reflect the complementary values of both techniques or, instead, reflect the added value of more samples, cannot be discerned from the numbers. The authors, however, favor complementarity and suggest that the CRP smear pattern can provide architectural information that can help with the assignment of a specific histologic tumor type.
Applications of imprint cytology to the evaluation of core biopsy samples have been studied most extensively for breast diseases and have received relatively scant investigation outside of this area.12345678910111213 That this is true was surprising to the author of this editorial, who, over the last several years, has had extensive hands-on experience using this technique to evaluate core needle biopsy specimens of a wide variety of lesions, including many lung masses. A recently published paper by Paulose and colleagues6 represents the largest study of touch imprints performed on core biopsy samples of the lung. This study focused on a slightly different question than did that of Chandan et al, and compared touch imprint cytology interpretations with the histologic interpretations of the parent core needle biopsy specimens, revealing sensitivity, specificity, positive predictive value, and negative predictive value of 89%, 100%, 100%, and 68%, respectively, for the imprint smear interpretations.6
In my institution, as at the institution where the study of Chandan et al was performed, pathologists perform rapid touch imprint cytology sampling on core needle lung biopsy specimens to ensure that the tissue acquired is adequate to establish a firm histologic diagnosis, for triaging tissue for additional studies (eg, cultures, flow cytometry, genetic studies, and electron microscopy), and for eliminating unnecessary additional passes. The downstream effects of our immediate interventions have resulted in numerous diagnoses of malignant neoplasms. Biopsy specimens manifesting opportunistic infections in immunocompromised patients and granulomatous infections in otherwise healthy people also have been appropriately sent for culture and histochemical staining due to the rapid evaluation of the sample. Counting the number of passes that theoretically were not performed, and the number of repeat procedures avoided, is something we have not pursued, but I am sure that these numbers are not negligible.
In fact, the topic of the article by Chandan et al touches on a greater issue, the potential for multispecialty collaboration to improve the quality of clinical care. Although pathologists often have had little involvement in procedural planning, the immediate assessment of an FNA sample and/or CRP, like the frozen section, incorporates the pathologist into this process and results in an improved procedural outcome.141516 Other opportunities exist for the proactive inclusion of the pathologist in the planning of diagnostic procedures. Most pathologists are trained in the selection of tests pertaining to the diagnosis of diseases in anatomic pathology samples. Deciding when a fresh tissue sample is needed for immunofluorescence, histochemical staining, flow cytometry, or gene rearrangement studies is covered in the typical anatomic pathology residency, and most pathologists can serve as resource personnel for clinicians who would like advice about when to consider performing these procedures. It is also to the advantage of the pathologist to supply this expertise, since the pathologist will eventually be responsible for interpreting the patient’s biopsy results, whether they come with or without the findings of additional studies.
A preprocedure consultation with the pathologist also can be helpful for deciding which surgical and/or cytologic procedure is best suited for the individual patient. Most benign processes in the lung, for example, cannot be definitively diagnosed by FNA and usually require the architectural information supplied by a biopsy specimen for diagnosis. Although interstitial lung diseases cannot always be diagnosed by transbronchial biopsy, in the right clinical and radiographic context transbronchial biopsies may supply enough information for the diagnosis of most of these disorders. For some interstitial lung diseases, however, a wedge biopsy is needed to document the appropriate histopathologic pattern.
Many practitioners and researchers have sought methods for obtaining the maximum information from tissue samples, while minimizing the various "costs" to the patient. The article by Chandan and colleagues provides us with one more route to achieve this goal. In this molecular age, I expect that we will see many more variations on this theme.
Footnotes
The author affirms that she has not received any financial support and is not involved with any organizations with financial interest in the subject matter.
References
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