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Pathologist Role in Tissue Acquisition for NSCLC Diagnosis

Insights From: Ben Levy, MD, Sibley Memorial Hospital; Andrew Lerner, MD, Sibley Memorial Hospital; Rasheda Persinger, AGNP-C, Sibley Memorial Hospital; Andrea Richardson, MD, PhD, Sibley Memorial Hospital
Published: Friday, May 25, 2018



Transcript: 

Benjamin P. Levy, MD: We can talk, Andrea, about your role as a pathologist for a lung cancer workup, but specifically after that, how do you interface with the interventional pulmonologist during this really critical time of getting the tissue?

Andrea Richardson, MD, PhD: Well, we generally are on call. We have a cytopathologist who’s on call every day, and when I look at the schedule and I see that there’s an EBUS case that Dr. Lerner has scheduled, I, as the doctor’s doctor, review the medical chart to look to see if the patient has a history of sarcoid or tuberculosis, if they’re a smoker or not, so that I know what to expect when I go in the room, what the differential diagnosis is going to be. And then in the procedure room, we have a microscope there, we have a staining set up there, and the cytopathologist is trained to be able to make a diagnosis just by looking at a smear of cells. A regular pathology analysis, like what we used to do in the old days when surgery was the standard, you get a lot more architecture and it’s a lot to tell. It takes some special skill to be able to tell with just amorphous cells on a slide. So, that’s what we’re trying to do. And we want to make sure that the needle is in the right place, so we’ll look for lymphocytes to make sure a lymph node has actually been sampled or not. And then we’re looking for malignant cells, and we’re trained to tell the difference between benign and malignant and kind of know the different cell types that we might encounter during the procedure.

Benjamin P. Levy, MD: So, how does this go down? Because I’m not in the room when this happens. Andrea, you do the biopsy, the slides are handed off, you look at them and you communicate to Andrew, we’ve got enough or you’re in the right spot. Is that generally the way it works? And if so, do you get more tissue after that, after we’ve confirmed you’re in the right area?

Andrea Richardson, MD, PhD: There are several different ways that we can prepare it. The smeared slide that can be air dried and stained in the room is only 1 way. It’s very critical that we have enough material in the cell block that gets processed the next day. And so, if we know we’re in the right spot, I will tell Dr. Lerner to do a couple of dedicated passes just for the cell block material. We want to make sure that all the material doesn’t end up on the slide because we can’t really do molecular studies on that. So, I am there to help triage the tissue, “Put more here,” or “No, we’re not seeing what we should see, you should do another pass.”

Benjamin P. Levy, MD: And how often does this happen when you’re in the room together? You’re working together as a team to get optimal tissue, but things aren’t perfect. And how often does it happen or what does happen when the message is, “Look, we need to go in a different place or we don’t have enough tissue”?

Andrew Lerner, MD: Historically, when a pathologist is not in the room, the teaching is you take 3 passes at 1 spot and you move to the next. I think that that has been shown in studies to be pretty sufficient. I think it’s the nuances of it that the on-site pathologist helps with. I’ll usually do, by convention, 3 passes in 1 area. Each gets stained on a slide and then you make a cell block or a clot for the remainder of that sample that’s within the needle. And then, if we just feel that the slide is pretty scant, there’s not enough, it’s not showing as much malignant cells, we may in fact do more passes there or move to a different site. It also helps guide, I think, which pass because sometimes my passes hit different parts of a lesion, and you could say the second one actually gave us the better sample. I’ll go back, take samples there that just go straight in the cell block. And it’s oftentimes how we work.

Andrea Richardson, MD, PhD: We’ve also had cases together where it’s not lung cancer, where it turns out that I look at it and it’s like, “This looks like lymphoma.” So, those cases have to be processed another way and sent for flow analysis. So, having that immediate feedback so that we can do the right thing to get a complete diagnosis is important.

Benjamin P. Levy, MD: It’s interesting. I learn something different every time I have discussions with you guys, including right now. I think I’ve learned additional layers of information here. It seems critical to have an on-site pathologist while you’re doing that procedure so you know exactly where you are, how much tissue you have, and it helps optimize the tissue acquisition. In the absence of that, I think it would be hard to know how much tissue to get.

Andrew Lerner, MD: Right. Yes, and there’s some. They’ve looked at this in certain studies showing that having a rapid on-site cytopathology evaluation, or ROSE as they call it, has improved diagnostic yields and limits the number of biopsies and places where you biopsy as well. Because without that, you’re going to do your full staging on a biopsy—your N3, N2, and N1 nodes because you really don’t know if they’re malignant—and even go out and sample the primary lesion as well, which really increases the risk of a lung pneumothorax or a lung puncture.

Andrea Richardson, MD, PhD: Sometimes we can make the diagnosis on the first pass of the first node and we can stop there.

Andrew Lerner, MD: Right, and we stop and it cuts the procedure time down significantly.

Transcript Edited for Clarity 
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Transcript: 

Benjamin P. Levy, MD: We can talk, Andrea, about your role as a pathologist for a lung cancer workup, but specifically after that, how do you interface with the interventional pulmonologist during this really critical time of getting the tissue?

Andrea Richardson, MD, PhD: Well, we generally are on call. We have a cytopathologist who’s on call every day, and when I look at the schedule and I see that there’s an EBUS case that Dr. Lerner has scheduled, I, as the doctor’s doctor, review the medical chart to look to see if the patient has a history of sarcoid or tuberculosis, if they’re a smoker or not, so that I know what to expect when I go in the room, what the differential diagnosis is going to be. And then in the procedure room, we have a microscope there, we have a staining set up there, and the cytopathologist is trained to be able to make a diagnosis just by looking at a smear of cells. A regular pathology analysis, like what we used to do in the old days when surgery was the standard, you get a lot more architecture and it’s a lot to tell. It takes some special skill to be able to tell with just amorphous cells on a slide. So, that’s what we’re trying to do. And we want to make sure that the needle is in the right place, so we’ll look for lymphocytes to make sure a lymph node has actually been sampled or not. And then we’re looking for malignant cells, and we’re trained to tell the difference between benign and malignant and kind of know the different cell types that we might encounter during the procedure.

Benjamin P. Levy, MD: So, how does this go down? Because I’m not in the room when this happens. Andrea, you do the biopsy, the slides are handed off, you look at them and you communicate to Andrew, we’ve got enough or you’re in the right spot. Is that generally the way it works? And if so, do you get more tissue after that, after we’ve confirmed you’re in the right area?

Andrea Richardson, MD, PhD: There are several different ways that we can prepare it. The smeared slide that can be air dried and stained in the room is only 1 way. It’s very critical that we have enough material in the cell block that gets processed the next day. And so, if we know we’re in the right spot, I will tell Dr. Lerner to do a couple of dedicated passes just for the cell block material. We want to make sure that all the material doesn’t end up on the slide because we can’t really do molecular studies on that. So, I am there to help triage the tissue, “Put more here,” or “No, we’re not seeing what we should see, you should do another pass.”

Benjamin P. Levy, MD: And how often does this happen when you’re in the room together? You’re working together as a team to get optimal tissue, but things aren’t perfect. And how often does it happen or what does happen when the message is, “Look, we need to go in a different place or we don’t have enough tissue”?

Andrew Lerner, MD: Historically, when a pathologist is not in the room, the teaching is you take 3 passes at 1 spot and you move to the next. I think that that has been shown in studies to be pretty sufficient. I think it’s the nuances of it that the on-site pathologist helps with. I’ll usually do, by convention, 3 passes in 1 area. Each gets stained on a slide and then you make a cell block or a clot for the remainder of that sample that’s within the needle. And then, if we just feel that the slide is pretty scant, there’s not enough, it’s not showing as much malignant cells, we may in fact do more passes there or move to a different site. It also helps guide, I think, which pass because sometimes my passes hit different parts of a lesion, and you could say the second one actually gave us the better sample. I’ll go back, take samples there that just go straight in the cell block. And it’s oftentimes how we work.

Andrea Richardson, MD, PhD: We’ve also had cases together where it’s not lung cancer, where it turns out that I look at it and it’s like, “This looks like lymphoma.” So, those cases have to be processed another way and sent for flow analysis. So, having that immediate feedback so that we can do the right thing to get a complete diagnosis is important.

Benjamin P. Levy, MD: It’s interesting. I learn something different every time I have discussions with you guys, including right now. I think I’ve learned additional layers of information here. It seems critical to have an on-site pathologist while you’re doing that procedure so you know exactly where you are, how much tissue you have, and it helps optimize the tissue acquisition. In the absence of that, I think it would be hard to know how much tissue to get.

Andrew Lerner, MD: Right. Yes, and there’s some. They’ve looked at this in certain studies showing that having a rapid on-site cytopathology evaluation, or ROSE as they call it, has improved diagnostic yields and limits the number of biopsies and places where you biopsy as well. Because without that, you’re going to do your full staging on a biopsy—your N3, N2, and N1 nodes because you really don’t know if they’re malignant—and even go out and sample the primary lesion as well, which really increases the risk of a lung pneumothorax or a lung puncture.

Andrea Richardson, MD, PhD: Sometimes we can make the diagnosis on the first pass of the first node and we can stop there.

Andrew Lerner, MD: Right, and we stop and it cuts the procedure time down significantly.

Transcript Edited for Clarity 
View Conference Coverage
Online CME Activities
TitleExpiration DateCME Credits
Medical Crossfire®: How to Use Liquid Biopsies Throughout the Lung Cancer Treatment Continuum OnlineJan 31, 20191.5
35th Annual Chemotherapy Foundation Symposium: Innovative Cancer Therapy for Tomorrow® Clinical Vignette SeriesJan 31, 20192.0
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