Slide 1

My talk today will be on the use of cytology for non-small cell lung carcinoma, in
particular its use in the diagnosis, subtyping, and the implications in the
management.
Cytology is one of the many interests I have in the field of pathology, and the
accuracy of fine needle aspirations for papillary thyroid carcinoma has been the
focus of clinical research in the past.

Slide 2
Here is an overview of what Im going to talk about today, a little on the history of
lung disease, the discussion of a case, and some of the advantages and disadvantages
of cytology, in particular fine needle aspirations, its accuracy, and how we use the
information we glean from our samples.

Slide 3
In undergrad, I studied Roman civilization, and focused primarily in Roman
medicine.
Cancer of the lung was first described as a disease in 1761 by Giovanni Battista
Morgagni, a professor of anatomy at the University of Padua.
I tried to search before that if there was any mention of lung tumor or disease and
came across this: a black-figure plate from Corinth in Greece dating to the 6
th

century BCE. Here we see miners digging for asbestos in one of the massive
quarries.
The Ancient Greeks used asbestos for the wicks of the eternal flames that lined
temples, as funeral coverings for kings during cremation, and, curiously, as napkins
that could be tossed into a fire to be cleaned.
Pliny the Elder, a Roman nobleman and scholar of nature and Roman medicine in
the 1
st
century CE, mentions a peculiar morbus pulmonum, or a sickness of the lungs,
which appeared to only afflict the slaves who worked in this mines. Galen, a Greek
physician and surgeon in Rome, describes this illness as a chronic cough,
accompanied by pallor and weakness that overcomes the older miners and
attributes this disease to the poor ventilation in the asbestos mines. Pliny mentions
the use of sheep bladders as rudimentary respirators.

Slide 4
Here is a cartoon depicting modern management of malignancies from a 2011 Cell
paper by Dr. Haber, the director of the Cancer Center here at MGH.
In genotype-directed cancer therapy, the malignant tumor specimen is subjected to
detailed biomarker analysis, including immunohistochemical as well as DNA-based
markers. These biomarkers are interpreted within the relevant signaling pathway to
identify a potential vulnerability for the cancer. Selection of an appropriate therapy
(often oral agents of limited toxicity) is dependent upon prior preclinical validation
of drug/genotype pairing and detailed analysis of drug/target interactions. Early
drug response and development of acquired resistance are monitored by repeat
biopsy of the tumor or, noninvasively, by functional imaging or circulating tumor
cell analysis.
Particularly relevant to lung cancer, with the advent of new targeted therapies that
depend on the histological subtyping of non-small cell lung cancers and on the
genotyping for tumor mutation status. And we shall cover some of those oncogenes
and the molecular therapies that are being used today.

Slide 5
This is an interesting case of a 53 year old man, never smoker, that we came across
during my week on lung with Dr. Mino-Kenudson. He initially presented in at an
outside hospital and later presented to this hospital in October 2011 with a chronic
cough. Here we see his CT from October 2011 showing a 8.1 cm x 7.7 cm x 3.5 cm
mass in the right upper lobe, extending from the apex to the right hilum. A right
axillary lymph node biopsy was performed and was called moderately differentiated
adenocarcinoma (CK7+, CK20-, TTF-1+, Napsin +). He was found to have multiple
mediastinal, bilateral hilar, and R axillary and supraclaviclar adenopathy, bone and
brain (nodules in parietal and temporal lobes) metastasis on PET and MRI.

Slide 6
At this time, a R lymph

Slide Est Number of Cancer Deaths
Here is a cartoon of the estimated cancer deaths in the US in 2014. An estimated
86,000 men and 72,000 women will die from lung cancer.
NSCLC accounts for about 80 to 85% of all lung cancers and is classified according to
the WHO criteria into three major types: adenocarcinoma (50%), squamous cell
carcinoma (30-35%), and large cell carcinoma (5-10%).
The median survival for non-small cell lung cancer is 8 to 10 months.

Slide Sampling Lung
Cartoon from a paper out of the University of Toronto.
Percutaneous transthoracic FNA
Bronchoscopic procedures: Brochoalevolar lavage/Endobronchial ultrasound-
guided transbronchial needle aspiration
Video-assisted thoracic surgery
Additionally, one can also examine sputum cytologically

Advantages of Cytology
Application in non-surgical candidates, much like our patient PB:
According to Syed Ali out of Hopkins, approximately 60% of patients with NSCLC
present with unresectable stage IIIB or IV disease, where the only pathologic
material guiding systemic therapy may be small biopsy or cytology specimens.

Accuracy, well discuss in a moment

Disadvantages
Choi et al out of Seoul looked at 458 patients who underwent transthoracic needle
biopsies under ultrasound or CT guidance found 22% of patients developed an
immediate pneumothorax and 3% developed delayed (more than 3 hours after the
procedure).
According to Berquist et al out of the Mayo Clinic, average hemoptysis incidence of
4.8% and pulmonary hemorrhage is uncommon with FNA. Use of a cutting needle
biopsy may result in pulmonary, endobronchial, or intraparenchymal hemorrhage,
as a result of laceration of a major pulmonary vessel in the process of obtaining a
core biopsy.
Air embolism: 10 out of 2200 biopsies in a case-control study over 11 years at 12
institutions in Japan to identify risk factors, found parenchymal hemorrhage during
procedure, lesions in lower lobe, and the use of larger biopsy needle.
Needle track metastasis: Roussel out of Rouen, France found that the risk of 1 out of
20,000 biopsies. He estimates that with the use of 22 gauge needles the risk is
lowered by a factor of 60.

Unsatisfactory yield
A) Needle well positioned within target tissue, but tumor may be heterogeneous
B) Needle has missed the target tangentially
C) Needle in central cystic/necrotic/hemorrhagic area devoid of diagnostic cells
D) Needle sampling a dominant benign mass but missing a small adjacent malignant
lesion
E) Fibrotic/desmoplastic target tissue giving a scant cell yield

Accuracy of Subtyping of FNA vs Core Needle Biopsy
Study out of MD Anderson
Poorly diff = Within the group of poorly differentiated nonsmall cell carcinomas,
minor differences between FNA and CNB diagnoses with regard to favoring
squamous vs glandular differentiation was not considered a typing discrepancy
because dual differentiation is common and the difference is not of therapeutic
relevance

Accuracy of Subtyping vs permenant
Memorial Sloan Kettering
Looked at FNA, Bronchial Brush, Wash,and Lavage.
ADC 93%
SqCC 89%
IHC raised accuracy to 100%

Molecular Testing
Because molecular testing on cytology is typically requested for patients with
advanced disease, this analysis was performed on a different cohort of patients than
the one used for the above cytologic/histologic correlation. Cyological specimens
submitted for mo- lecular testing during the study period (n = 128) included
transthoracic and transbronchial FNAs (n = 67), extrathoracic FNAs (n = 29), pleural
effusions (n = 29), and bronchial brush/wash specimens (n = 3). Of these, 126 (98%)
were suitable for EGFR/KRAS testing, whereas two cases were not analyzable due to
PCR failure (both failures were from poorly preserved specimens submitted from
outside institutions). Of 126 analyzable samples, EGFR mutations were identified in
31 (25%) and KRAS mutations in 25 (20%) cases.
Approximately 1300 cells was the average cellularity of successful samples, which
average 0.76 micrograms of DNA
FNA and surgical specimens provide the best yield of DNA for genotyping
Fluid cytology tends to be lower yield for DNA content

Histological Subtype-based treatment
Erolotinib
KRAS mutations may sensitize tumors to antifolates Pemetrexed possibly by
upregulating mir-181c, a microRNA that can downregulate KRAS.
Sandler A et al. N Engl J Med. 2006;355:2542-2550. bevacizumab 17.7 months vs 7.4
Scagliotti GV et al. J Clin Oncol. 2008;26:3543-3551. pemetrexed 12.6 months vs.
10.9 gemcitabine for sqcc 10.8 months vs 9.4
Fossella F et al. J Clin Oncol. 2003;21:3016-3024.