BronchoAlveolar Lavage (BAL) Cytology. Bronchoalveolar lavage «liquid lung biopsy»

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Gordon Shaw
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1 BronchoAlveolar Lavage (BAL) Cytology Bronchoalveolar lavage «liquid lung biopsy» Joëlle WALLON Cytology Flow cytometry Microbiology Molecular biology Mineralogy Research 2 1

2 BAL clinical indication Suspicion of interstitial lung disease : Clinic dyspnea Imaging bilateral diffuse lung infiltration Function restrictive syndrome Biology hypoxemia ml Clinical procedure ml Etiology : Unknown Drugs and toxics Organic and inorganic dusts Infectious microorganisms Neoplastic lung infiltration 3 Avoid bronchial contamination! 4 Sent immediately to the lab! 2

3 Cytological techniques BAL in healthynon-smokers Removal ofmucus : filter through 2 layers of gauze Total cell count Differential cell count Lymphocyte subpopulation typing Hemocytometer Cyto/centrifugationMGG smears Immunocyto-chemistry Flow cytometry Inflammatory cells : Macrophages > 80 % Lymphocytes < 10 % Neutrophils < 1 % Cytological screening MGG, Papanicolaou, Perls, PAS, Grocott, Immunocytochem. Clean background Epithelial cells < 5 % 5 6 3

4 BAL findings Specimen adequacy > 20 well preserved macrophages/hpf < 5 % epithelial cells No obscuring mucopurulent exudate Quantitative cytology Differential cell count of inflammatory cells Lymphocyte subpopulation typing, CD4/CD8 Qualitative cytology Cells Non-cellular contents 7 QUANTITATIVE EVALUATION Normal cell count : 600 cells on MGG smear Total Cell/ml Macrophages Lymphocytes Neutrophils Eosinophils Mast Cells NON-SMOKERS 100 x % 10 % 1% < 1% < 1% Clean background SMOKERS 400 x % 1 % 1-4 % < 1 % < 1 % 8 4

5 Lympho < 10 % 20-30% Quantitative evaluation BAL lymphocytosis CD4/CD > Normal Sarcoidosis Tuberculosis Lymphangitis Ca Quantitative evaluation BAL in Sarcoidosis Findings : 28 % Lymphocytes CD4/CD8 = 5 Specificity 97 % BAL may replace biopsy! > 50 % <1.3 Hypersensitivity pneu. Drug-induced alveolitis predicts good response to corticoids

6 Quantitative evaluation BAL neutrophilia Quantitative evaluation Adult Respiratory Distress Syndrome < 1 % <10-15 % Normal Lung fibrosis Hypersensitivity pneumonia Findings : % Neutrophils Atypical II pneumocytes > 20 % Infection ARDS predicts bad response to corticoids fibrosis bad prognosis 11 Excluding : Alveolar hemorrhage Acute eosinophilic pneu. DD : Carcinoma Bacterial pneumonia 12 6

7 Quantitative evaluation BAL normal findings Exlude diagnoses : Active sarcoidosis Hypersensitivity pneumonia Eosinophilic pneumonia Alveolar hemorrhage syndrome Berylliosis Alveolar proteinosis QUALITATIVE ANALYSIS CYTOLOGICAL SCREENING Alveolar macrophages Bi- or multinucleation Cytoplasmic inclusions Cytoplasmic vacuolization Background Ferruginous bodies Alveolar proteinosis Infectious microorganisms Neoplastic cells

8 Macrophages : nucleus Macrophages : cytoplasm Binucleation Normal Smokers Aspecific Multinucleation Inflammation Granuloma Tuberculosis Sarcoidosis Hypersensitivity pn. Inclusion virus 15 Cytoplasmic inclusions Smokers Inorganic dust Asbestosis Histoplasma capsulatum Hemosiderin 16 8

9 Macrophages : cytoplasm Macrophages : cytoplasm MGG Pap Hemosiderin = alveolar hemorrhage Perls : > 30 % (+) macrophages Golde score : Score >100 = alveolar hemorrhagic process Cytoplasmic vacuolization Foamy cytoplasm Hypersensitivity pneu. Drug-induced alveolitis Aspiration pneumonia Oil red-o + > 5 % macrophages Perls

10 Abnormal Background Exogenous particles Asbestos : ferruginous bodies Abnormal Background Extracellular material : Alveolar proteinosis 19 MGG PAP PAS 20 10

11 QUALITATIVE ANALYSIS OPPORTUNISTIC INFECTIONS Immunosuppressed patients AIDS Chemotherapy Posttransplantation Microorganisms Pneumocystis jiroveci CMV Aspergillus Mycobacteria 21 Diagnosis of lung infections Diagnostic Pneumocystis Toxoplasma Strongyloides Legionella Cryptoccus Histoplasma Mycobact. Tuberc. Influenza virus RSV Colonization possible Bacteria Herpes simplex CMV Aspergillus Candida Atypical mycobact

12 Pneumocystis jiroveci Pneumocystis carinii f.sp. hominis Pneumocystis jiroveci Methods of diagnosis: No culture! PCR? Cytology : Specificity 100 % Pap Extracellular material Cysts + Trophozoites Grocott MGG Immuno Grocott MGG

13 Owl eye cell CMV pneumonia Colonization or infection? Cfr clinics! QUALITATIVE ANALYSIS MALIGNANT CELLS Epithelial cells Bronchoalveolar carcinoma Lymphangitis carcinomatosa Breast, stomach, kidney, colon, bladder Non-epithelial cells : Lymphoma Kaposi sarcoma

14 Abnormal epithelial cells Bronchoalveolar Ca Metastatic Ca Breast, Kidney, Bladder Lymphocytosis % DD : Hyperplastic type II pneumocytes BAL as a diagnostic tool Total cell count Differential cell count Lymphocyte subpopulation Cytological findings must be integrated with 27 Clinics Imaging Lung function tests Biology 28 14

15 Conclusion Clinicalindications : Interstitial lung disease Qualitative cytology Prognostic evaluation Opportunistic infections Detection of infiltrative lung tumor Evaluate carefully any morphological detail! 29 15

Cytology : first alert of mesothelioma? Professor B. Weynand, UCL Yvoir, Belgium

Cytology : first alert of mesothelioma? Professor B. Weynand, UCL Yvoir, Belgium Introduction 3 cavities with the same embryologic origin the mesoderme Pleura Exudates Pleura Peritoneum Pericardium 22%