. Step 12 of 41
Clinical Stem 1
Non-smoking female with a new right upper lobe lung mass and three PET-positive mediastinal lymph nodes

Answer B
All choices are reasonable options. Bronchoscopists should communicate with the pathology department in their institutions to determine a level of confidence for diagnosing lung carcinoma using rapid on-site evaluation. In general, there is a good correlation between ROSE and the final cytologic diagnosis, so ending the procedure may be appropriate. In this case, after specimen adequacy was established and the diagnosis of malignancy was made by N3 node involvement, the tumor was classified stage III B; therefore, the procedure could end after the first two aspirates. In part, this is because evidence suggests that optimal results are obtained after three aspirations per lymph node station or after two aspirations per station when at least one tissue-core specimen is obtained by the first or second aspiration.

Obtaining at least two additional aspirates from station 4L, however, is highly desirable in this patient because adequate specimen is needed for molecular analysis. Sampling station 7 and 4R is also appropriate as more tissue is needed for downstream molecular analysis. Additional samples would not be necessary for staging.

ROSE helps to confirm the presence of malignant cells and the adequate cellularity of the sample before submitting it to the molecular pathology laboratory. Some practitioners do not use ROSE because it can increase the duration and cost of the procedure. Sending the specimen directly for molecular analysis without first confirming the presence of malignancy, however, may not be cost effective because biopsy specimens may not contain sufficient carcinoma cells suitable for molecular testing.
If this patient's diagnosis is confirmed to be adenocarcinoma as suspected using ROSE, biomarker-directed therapy might be considered as first or second line treatment for locally advanced disease depending on biomarker analysis. Adequate specimens are therefore needed. For instance, specimens are considered adequate for EGFR analysis if they contain more than 40% malignant cells which could be obtained by four "good" fine needle aspirations or 2 or 3 core needle tissue biopsies.

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References:
  1. Lee HS, Lee GK, Lee HS, et al. Real-time endobronchial ultrasound-guided transbronchial needle aspiration in mediastinal staging of non-small cell lung cancer: how many aspirations per target lymph node station? Chest. 2008;134:368-74
  2. http://labmed.ucsf.edu/uploads/369/166_24JonesMolecularPathologyOfLungCancer.pdf (accessed 8/23/11).
  3. Coghlin CL, Smith LJ, Bakar S, et al. Quantitative analysis of tumor in bronchial biopsy specimens. J Thorac Oncol. 2010;5:448-52.
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