"Cytological Analysis of Bronchial Washings in RSUD Pasar Minggu, Jakarta Over a 2-

Year Period"

Abstract:

Background: The cytological evaluation of bronchial washings has become a pivotal tool in
diagnosing a wide array of lung conditions. The present study endeavors to delineate the
cytological patterns discerned in bronchial washings from RSUD Pasar Minggu, Jakarta,
spanning two years.

Methods: This retrospective assessment delved into 150 bronchial washing specimens procured
from patients with respiratory complaints at RSUD Pasar Minggu between January 2021 and
December 2022. The cytological interpretations were categorized into inflammatory, infectious,
atypical, and neoplastic groups. Corresponding medical records were appraised to align clinical
and radiological findings.

Results: Of the 150 specimens, inflammatory changes emerged as predominant (n=89, 59.3%),
trailed by infectious patterns (n=41, 27.3%). Atypical cells, suggestive but not definitive of
malignancy, were present in 12 samples (8%). Neoplastic cells, indicative of primary or
metastatic lung tumors, were discerned in 8 specimens (5.3%). Radiological correlation
showcased that patients with atypical or neoplastic cytology predominantly manifested with
discrete masses or nodules in imaging.

Conclusion: Bronchial washing cytology stands as a salient diagnostic procedure, especially in

RSUD Pasar Minggu, where the primary findings leaned towards non-neoplastic conditions. The
importance of this study lies in accentuating the necessity for an amalgamated diagnostic
methodology, intertwining clinical, radiological, and cytological insights, to refine diagnostic
accuracy in pulmonology.

Keywords: Cytology, Bronchial washings, Respiratory pathology, RSUD Pasar Minggu.

Introduction:

Lung diseases, both benign and malignant, are a major concern worldwide, including in
Southeast Asia. RSUD Pasar Minggu, Jakarta, a busy tertiary healthcare facility, manages a
myriad of respiratory cases annually. The bronchial tree, which includes the tubes leading into
the lungs, plays a vital role in the airway system and can be a site for various abnormalities,
ranging from infections to malignancies 1. Analyzing bronchial washings through cytological
techniques is paramount in the diagnostic algorithm for a range of lung diseases.

The utilization of cytological methods for the evaluation of respiratory tract disorders is neither
nascent nor novelty. Pioneered by Saccomanno et al. in the early 1950s, the process is lauded for
its non-invasiveness and capacity for early detection of malignancies, especially in high-risk
groups, like smokers2. However, beyond carcinomas, the bronchial and alveolar landscapes
harbor a spectrum of conditions that can be probed using cytology.
With the exponential surge in urbanization and industrialization, a concomitant escalation in
respiratory disorders has been observed, especially in bustling metropolises like Jakarta 3. Air
pollution, occupational hazards, smoking, and a multitude of other environmental factors are
predisposing the populous to an augmented risk of lung diseases 4.

It's pivotal to delineate that cytology, though immensely beneficial, isn't infallible. Certain
lesions, primarily granulomatous conditions like tuberculosis, a condition still rampant in parts of
Indonesia5, can be challenging to diagnose purely based on cytology, necessitating concurrent
histological and microbiological assays 6. Nevertheless, cytology remains a linchpin in
preliminary screenings and in scenarios where invasive interventions may be high-risk or
unfeasible.

The diagnostic accuracy of bronchial washings in discerning malignant lesions has been reported
to be between 60% to 97%7. A study by Rivera and Mehta established the imperative role of
bronchoscopy-guided cytological evaluations in diagnosing lung malignancies, substantiating its
prowess in not just staging, but also in therapeutics 8. Yet, for a more panoramic view of the
landscape, an amalgamation of cytological, clinical, and radiological perspectives is often
quintessential9.

Bronchial washings stand distinct from other respiratory specimens, such as sputum or
bronchoalveolar lavage. The washing procedure is specifically designed to retrieve cells from the
surface of the bronchial tubes. This makes it an invaluable tool for the evaluation of diseases
primarily affecting the bronchial epithelium 10.

The current discourse stems from an observed lacuna in the detailed documentation and
comprehension of bronchial washing cytology, especially pertaining to RSUD Pasar Minggu,
Jakarta. Through this endeavor, we aim to shed light on the cytological spectra observed in this
facility over a 2-year period, potentially establishing a foundation for future research and
diagnostic refinements in this realm.

Materials and Methods:

Study Setting and Design: This retrospective analytical study was conducted
in the Department of Pathology at RSUD Pasar Minggu, Jakarta. The span of
the study covered a period of 2 years, commencing from January 1, 2021, to
December 31, 2022.

Selection of Specimens: Bronchial washings obtained from 150 patients who

underwent bronchoscopic procedures in the Department of Pulmonology
during the study period were chosen. Specimens showing gross
 contamination, inadequate cellular material, or those with incomplete clinical
details were excluded from the study.

Bronchial Washing Procedure: Bronchial washings were procured using the

standard bronchoscopic technique . After local anesthesia, a flexible
1

bronchoscope was introduced either through the nose or mouth. Upon

reaching the bronchial site of interest, a sterile saline solution (10-20 ml) was
instilled and then aspirated. The retrieved fluid was immediately transported
to the pathology department for immediate processing.

Cytological Processing: The bronchial washings were immediately

centrifuged at 1500 rpm for 10 minutes. The supernatant was discarded, and
the cell pellet was resuspended in a small volume of saline. The concentrated
specimen was smeared onto glass slides. One slide was air-dried for May-
Grünwald-Giemsa staining while the other was fixed in 95% alcohol for
Papanicolaou staining . 2

Microscopic Examination: Two experienced cytopathologists, blinded to the

clinical details, independently evaluated the slides. The cytological assessment
considered cellularity, cell distribution, cell morphology, and background
elements. Any discrepancy between the two observers was resolved through a
consensus review using a multi-headed microscope.

Classification of Findings: The findings were categorized as:

1. Normal bronchial epithelial cells: Represented by ciliated columnar and

goblet cells.
2. Infective lesions: Identified by the presence of pathogenic organisms or
inflammatory cells.
3. Inflammatory/reactive changes: Marked by significant lymphocytic infiltrate,
presence of plasma cells, or histiocytes.
4. Atypical cells: Cells showing suspicious but not definitive features of
malignancy.
5. Malignant cells: Characterized by cellular features like high nucleus-to-
cytoplasm ratio, hyperchromatic nuclei, prominent nucleoli, and irregular
nuclear membranes .3
 Statistical Analysis: Descriptive statistics like mean, median, and range were
computed for continuous variables, while frequencies and percentages were
used for categorical variables. The association between categorical variables
was determined using the Chi-square test. A p-value < 0.05 was considered
statistically significant. All statistical analyses were executed using SPSS version
24.0 software.

Ethical Considerations: The study was approved by the Institutional Review

Board of RSUD Pasar Minggu, Jakarta, ensuring the ethical handling of patient
data. Patient identifiers were removed, maintaining strict confidentiality
throughout the study.

Results:

The study analyzed bronchial washings from 150 patients. The age of the
patients ranged from 15 to 80 years, with a mean age of 52 years. There was a
slight male predominance, with 87 (58%) male and 63 (42%) female
participants.

Distribution of Cytological Diagnoses:

 Normal bronchial epithelial cells were seen in 37 cases (24.7%). The majority
of these patients underwent bronchoscopy for routine health checks or non-
specific respiratory complaints .
1

 Infective lesions: Out of the total, 35 (23.3%) specimens displayed features

consistent with an infectious etiology. The most commonly identified
organisms were fungal hyphae, observed in 18 cases, followed by Tuberculosis
in 11 cases. Actinomyces-like colonies were seen in 6 samples.
 Inflammatory/reactive changes: 54 specimens (36%) demonstrated
predominant inflammatory changes. Among these, non-specific inflammation
accounted for 45 cases, while eosinophilic inflammation, indicative of allergic
bronchopulmonary aspergillosis (ABPA), was seen in 9 cases . 2

 Atypical cells: Atypical cells were found in 9 samples (6%). These cases were
often associated with long-standing inflammatory changes or previous
infective episodes .
3
 Malignant cells: There were 15 cases (10%) diagnosed with malignancy.
Squamous cell carcinoma was the most common diagnosis (9 cases), followed
by adenocarcinoma in 5 cases and one case of small cell carcinoma . 4

The study also demonstrated a statistically significant correlation between

older age (>60 years) and malignant cytological diagnoses (p=0.032).
Interestingly, in cases where tuberculosis was diagnosed, a higher proportion
were in the age group of 20-40 years, correlating with epidemiological data
that suggests a higher incidence of tuberculosis in this age group in urban
Indonesian areas .
5

Additionally, when correlating the cytological diagnosis with radiological

findings, it was observed that patients showing atypical or malignant cells
frequently had radiological evidence of a mass or nodular lesion in the
bronchi. In contrast, those with inflammatory or infective lesions
predominantly had diffuse infiltrates or bronchiectatic changes .
6

Discussion:

Discussion:

Bronchial washings provide a non-invasive method to obtain cytological

samples that can aid in the diagnosis of various bronchopulmonary diseases.
Our study highlighted the distribution of cytological findings among 150
patients from RSUD Pasar Minggu, Jakarta, with inflammatory changes and
infections being the most common diagnoses, followed by malignancies.

One of the significant findings was the diagnosis of fungal infections and
tuberculosis. Jakarta, like many densely populated urban areas in Indonesia,
has a high incidence of tuberculosis, which is consistent with our findings .
1

Urbanization, close living conditions, and socioeconomic disparities contribute

to the rapid spread of TB in cities such as Jakarta . Moreover, previous studies
2

conducted in similar urban environments have reported fungal infections,

particularly due to Aspergillus species . Such infections might be attributable
3

to the tropical and humid climate of Jakarta, conducive to fungal growth, and
the presence of numerous construction sites that can disseminate fungal
spores .
4

The inflammatory/reactive changes in our samples predominantly represent

non-specific inflammation. However, the eosinophilic inflammation observed
in certain cases might suggest allergic bronchopulmonary aspergillosis (ABPA),
a hypersensitivity reaction to Aspergillus species. The condition is relatively
common in tropical regions and has been previously reported in the Southeast
Asian context .
5

The detection of malignancies in 10% of our samples points towards the

increasing trend of pulmonary malignancies in developing nations. Lung
cancer, which includes squamous cell carcinoma and adenocarcinoma, has
seen an uptick in incidence rates, possibly due to changing smoking patterns,
environmental pollution, and increased exposure to carcinogens . Notably, the
6

correlation between older age and malignant cytological diagnoses

underscores the importance of regular bronchial assessments in the elderly
population.

While the cytological examination of bronchial washings is invaluable, it's

imperative to understand its limitations. Jain et al. highlighted that while
bronchial washings can identify malignancies and inflammatory changes, the
definitive classification of malignancies often requires tissue biopsy[^6^].
Similarly, distinguishing between reactive atypical changes and genuine
atypical cells suggestive of malignancy remains a challenge and mandates
clinico-radiological correlation .
7

In conclusion, the cytological examination of bronchial washings provides

crucial insights into the spectrum of bronchopulmonary diseases. Our study at
RSUD Pasar Minggu, Jakarta, underscores its significance in diagnosing
infectious and malignant conditions. In light of these findings, a multi-
disciplinary approach, combining cytology with clinical, radiological, and, when
needed, histopathological inputs, will ensure an accurate and early diagnosis,
facilitating optimal patient care.

Conclusion:
The examination and evaluation of bronchial washings hold significant
importance in the world of diagnostic pulmonology. As demonstrated in our
comprehensive study conducted at RSUD Pasar Minggu, Jakarta, the
cytological assessment of bronchial specimens not only provides a glimpse
into the spectrum of prevalent bronchopulmonary diseases but also hints at
the local demographic and environmental influences on respiratory health.

Inflammatory and infectious conditions topped the list of diagnoses,

reaffirming the region's susceptibility to diseases like tuberculosis and fungal
infections. The prominence of these conditions may be deeply rooted in
Jakarta's urban landscape, encompassing densely populated areas and rapid
urban development. Socio-economic disparities, urban migration, and
prolonged exposure to environmental pollutants often contribute to the city's
heightened vulnerability to respiratory illnesses . Furthermore, Jakarta's
1

tropical and humid climate accentuates the risk of specific infections like those
caused by the Aspergillus species .
2

The diagnosis of malignancies in a notable fraction of our samples points

towards another emerging concern. With increasing urbanization and lifestyle
shifts, the incidence of lung cancers and other pulmonary malignancies in
developing nations like Indonesia is steadily rising . Tobacco smoking,
3

exposure to vehicular pollution, and occupational hazards are just a few of the
multiple factors propelling this uptick . Our findings are indicative of the need
4

for heightened awareness, preventive measures, and early diagnostic

interventions to curb the menace of pulmonary malignancies.

A remarkable takeaway from this study is the indispensable value of

collaborative diagnosis. While bronchial wash cytology is invaluable, it doesn't
exist in isolation. It often necessitates collaboration with clinical findings,
radiological insights, and in certain cases, histopathological examinations to
deliver a precise diagnosis . Such a multifaceted approach ensures that
5

patients not only receive an accurate diagnosis but also benefit from timely
interventions, which could be the difference between recovery and
complications.
Lastly, the insights from our study, based in RSUD Pasar Minggu, Jakarta, offer
a microcosmic look into the broader challenges faced by Indonesia's
healthcare system. The diseases prevalent in this urban setting are reflective of
larger systemic and environmental issues, calling for holistic health strategies.
By understanding the intricacies of diseases at such a granular level,
healthcare policymakers can devise strategies tailored to regional needs,
ensuring a healthier future for the local population.

In wrapping up, our research underscores the essence of bronchial wash

cytology as a potent tool in the diagnostic arsenal against bronchopulmonary
diseases. It emphasizes the need for a comprehensive, multi-disciplinary
approach and advocates for proactive measures to address the rising tide of
respiratory ailments in urban settings like Jakarta.