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Pulmonary Pathology Online

Histopathological Reporting of Bronchial Biopsy Specimens

Dr Sampurna Roy MD

 

                                                                                                                      

 

Indication:

- The main indication for bronchial biopsy is diagnosis of bronchogenic neoplasia. For bronchoscopically visible tumours diagnosis is possible in up to 90% of cases.

- A wide range of other endobronchial and bronchial wall lesions (including inflammatory lesions) can be sampled.

 

Most bronchial biopsies are taken to identify neoplasia or inflammatory disease.

On small biopsies it may not be possible to classify a neoplasm more precisely than small cell or non-small cell carcinoma.

Squamous cell carcinoma should not be diagnosed without evidence of stratification, intercellular bridges (prickles) and keratinization.

Because many lung tumors are polymorphic it is often difficult to assess the degree of differentiation reliably on small biopsies.

It has been suggested that the term 'undifferentiated large cell carcinoma' should be avoided on biopsy material.

The presence of crush artifact is sometimes considered a useful clue that the tumor is a small cell carcinoma.

This is not a reliable indicator. Well-preserved tumour cells with the characteristic nuclear features must be seen.

Crushed lymphoid follicles and crushed areas of chronic inflammation can have identical appearances.

Immunohistochemistry with CD45 and an epithelial marker help in even the most difficult cases.

Many tumours that in the past were diagnosed as 'bronchial adenoma' were not benign but were examples of carcinoid tumor, adenoid cyst carcinoma, mucoepidermoid carcinoma or lymphoma.

True benign bronchial tumors include lipoma, hamartoma, granular cell tumor,  squamous cell papilloma and mucous cell adenoma.

Another condition that can be confused clinically with a neoplasm is nodular bronchopulmonary amyloidosis.

This is an isolated form of AL amyloidosis in which nodules distort and occlude airways.

Typical fibrillar eosinophilic material is associated with an infiltrate of plasma cells and giant cells.

 

- The rigid bronchoscope can be used as a diagnostic and therapeutic tool.

These are used in the extraction of inspissated mucoid plugs, blood clot and aspirated foreign material.

It may also be used for endobronchial resection of carcinoid tumors.

- The rigid bronchoscope is also the instrument of choice for biopsying vascular neoplasms.

 

The biopsy site is limited to lobar and some segmental bronchi.

- Flexible fibreoptic bronchoscopy requires topical airway anesthesia and is useful for investigation and biopsy of the subsegmental bronchi.

Approximately 10% lung cancers are resected so the majority of therapeutic decisions are based on small biopsy / cytological diagnosis.

Diagnostic correlation between preoperative biopsy and resection is higher for small cell carcinomas, intermediate for squamous cell carcinoma and lowest for adenocarcinoma.

There is significant interobserver variation in the histological typing of non-small cell cancers.

Some authors have suggested use of the less precise term 'non-small cell lung cancer - not otherwise specified' in biopsy specimens. (For the management of these heterogenous group of tumour further subclassification is not required. )

Preoperative histological classification of primary lung cancer: accuracy of diagnosis and use of the non-small cell category.J Clin Pathol. 2000 Jul;53(7):537-40

 

A small amount of lung parenchyma may be included in a bronchial biopsy.

Assessment of interstitial changes on small parabronchial fragments should be made with caution - the results may not be representative of the parenchyma away from this area and may be misleading.

 

An approach to histopathological reporting of a bronchial biopsy:

- The report should contain information on the adequacy of the biopsy and the tissues and other material present.

- When disease is identified, the report should indicate whether the primary disease is neoplastic or inflammatory.

(I) For biopsies showing dysplasia the report should comment on the:

- severity of the dysplasia: mild, moderate, severe, carcinoma in situ:

- presence of associated inflammatory changes:

(II) For invasive malignant tumour, the report should comment on the:

Tumour type:  

- Primary lung carcinoma:   small cell carcinoma ;  non-small cell carcinoma (squamous or glandular differentiation); mixed types; other distinctive types of carcinoma - giant cell carcinoma;

- Non-epithelial malignancy:   Lymphoma ; Sarcoma.

- Metastatic tumour;

Degree of differentiation (if assessable):

Tissues involved by the tumor. Example:  Cartilage:

Presence of vascular invasion.

Presence of associated metaplasia or dysplasia in surface epithelium.

III) Presence of associated inflammatory changes:

For biopsies showing bronchial inflammation the report should comment on the:  

Mucosa:  Ulceration ; presence and type of intraepithelial inflammatory cells ; relative number of goblet cells; presence of squamous metaplasia ; thickening of the basement membrane (Example: Asthma) ; viral inclusions in surface epithelial cells.

Submucosa:  Acute inflammation ; non-specific chronic inflammation ; Eosinophilic inflammation (Example: Asthma, Churg-Strauss disease, parasitic infestation such as helminthiasis) ; Granulomatous inflammation :

(Example: Sarcoidosis, tuberculosis, allergic bronchopulmonary aspergillosis, bronchocentric granulomatosis) ; Vasculitis (Example: Wegener’s granulomatosis, polyarteritis nodosa - PAN , Churg-Strauss disease).

Luminal contents: Presence of mucus and inflammatory cells, particularly neutrophils , eosinophils ; fungal elements such as Aspergillus and foreign material.

Cartilage: Osseous metaplasia as in bronchopathia osteoplastica ; inflammation as in relapsing polychondritis.

 

Further reading:

Bronchoscopic and percutaneous aspiration biopsy in the diagnosis of bronchial carcinoma cell type.

Diagnosis of lung cancer by fibreoptic bronchoscopy: problems in the histological classification of non-small cell carcinomas.

How reliable is the diagnosis of lung cancer using small biopsy specimens? Report of a UKCCCR Lung Cancer Working Party.

Fibreoptic bronchoscopy: effect of multiple bronchial biopsies on diagnostic yield in bronchial carcinoma.

Observer variability in histopathological reporting of non-small cell lung carcinoma on bronchial biopsy specimens.

Observer variability in histopathological reporting of malignant bronchial biopsy specimens.

 

 

Dr Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)

 


 

 

 

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