Bronchoalveolar Lavage in Malignancy - Semantic Scholar

Bronchoalveolar Lavage in Malignancy Q1

VenerinoQ1 Poletti, M.D.,3 Giovanni Poletti, M.D.,1 Bruno Murer, M.D.,2 Luca Saragoni, M.D.,3 and Marco Chilosi, M.D.4

ABSTRACT

Bronchoalveolar lavage is a useful diagnostic tool in diffuse or disseminated lung malignancies that do not involve the bronchial structures visible by endoscopy. The neoplastic histotype and the intraparenchymal neoplastic growth pattern are good predictors for diagnostic yield; adenocarcinoma, and tumors with lymphangitic or lepidic growth patterns more easily diagnosed by bronchoalveolar lavage; in these cases the diagnostic yield reported is higher than 80%. In hematologic malignancies the diagnostic yield is quite good in secondary diffuse indolent B cell lymphomas and in primary B cell lymphomas of mucosa-associated lymphoid tissue (MALTQ3) type but low in Hodgkin disease. Morphological analysis may be implemented by immunocytochemical or molecular tests to identify the cell lineage and the presence of monoclonality. Disorders in which bronchioloalveolar cell hyperplasia/dysplasia is a significant morphological component may have cytological features in bronchoalveolar lavage fluid that mimic lung neoplasms: acute respiratory distress syndrome (ARDS), acute interstitial pneumonitis (AIP), and acute exacerbation of idiopathic pulmonary fibrosis are the most important clinical entities in this group.

Q3

KEYWORDS: Bronchoalveolar lavage, bronchioloalveolar cell carcinoma, lymphoproliferative lung disorders, carcinomatou lymphangitis, lung neoplasms

T

Q2 534

he diagnosis of diffuse neoplastic involvement is a major and growing diagnostic problem for pulmonologists because such events may mimic nonneoplastic infectious, inflammatory, and metabolic disorders. The problem is compounded in patients with a history of chemotherapy or radiotherapy or in subjects immunocompromised for a variety of causes. In this clinical setting bronchoalveolar lavage (BAL) may have a relevant diagnostic role in detecting neoplastic cells or suggesting an alternative diagnosis.1,2 The comprehension of BAL’s role in diagnosis of lung tumors is based upon three points: the growth pattern and cytological characteristics of tumors in the lung parenchyma, the

correlations between morphology and imaging features, and the diagnostic value added by new investigative techniques such as immunocytochemistry, flow cytometry, and molecular biology techniques.

1 Department of Clinical Pathology, Ospedale Santa Maria delle Croci, Ravenna, Italy; 2Department of Surgical Pathology, Ospedale Umberto I, Mestre, Italy; 3Department of Anatomic Pathology, Ospedale GB Morgagni, Forlı`, Italy; 4Department of Pathology, University of Verona, Verona, ItalyQ2. Address for correspondence and reprint requests: Venerino Poletti, M.D., Department of Anatomic Pathology, Ospedale GB Morgagni,

Via C Forlanini 34, 47100 Forlı`, Italy (e-mail: [email protected]). Bronchoalveolar Lavage; Guest Editors, Robert P. Baughman, M.D., Ulrich Costabel, M.D., and Keith C. Meyer, M.D. Semin Respir Crit Care Med 2007;28:534–545. Copyright # 2007 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. DOI 10.1055/s-2007-991526. ISSN 1069-3424.

DIFFUSE LUNG TUMORS: MORPHOLOGICAL AND IMAGING CORRELATIONS The lungs are the organ system that acquires the most metastases of any system in the entire body. This is related to several unique features of the lungs: they receive the entire cardiac output every minute, they

BAL IN MALIGNANCY/POLETTI ET AL

Q4

Q7

have the densest capillary bed in the body, they are the first capillary plexus met after most of the lymphatic drainage enters the venous system, and they consist of delicate membranes that may be beneficial for drawing on nearby oxygenated air for sustenance.3 The most common situation is presentation in patients with known extrapulmonary solid neoplasm; in this setting metastases are correctly identified in the majority of cases without the need for invasive procedures.4 However, especially when the primary tumor is still unidentified, or when the clinical features and laboratory findings are atypical or confusing, or the tumors are of mesenchymal origin, disseminated lung neoplasms may imitate other diffuse infiltrative lung diseases either for the clinical profile or for the radiographic findings.5–13 Also, multifocal primary lung neoplasms may present clinical and imaging features overlapping those observed in nonmalignant diffuse lung diseases.5,7,8,14 Tumors infiltrate or growQ4 in the lung parenchyma, giving rise to different histopathological patterns (Table 1). A lepidic pattern is characterized by neoplastic cells growing along alveolar walls replacing the normal lining cells without altering the interstitial tissue.14 This growth pattern is typically observed in bronchioloalveolar cell carcinoma (BAC) (Fig. 1), but it may also be present in parenchymal lung metastases due to tumors originating in the gastrointestinal tract, pancreas, prostate, breasts, thyroid, ovary, and pleural mesothelium.15,16 When the tumor cells and their secretionary products fill the alveolar spaces, histopathology at low power is similar to that observed in infectious lobar pneumonia (pneumonia-like growth pattern) or in desquamative interstitial pneumoTable 1 Q7 Histopathological Patterns of Neoplastic Intraparenchymal Lung Growth and Corresponding High-Resolution Computed Tomographic Scan Features Histopathological Patterns of Neoplastic Intraparenchymal Lung Growth Lepidic

High-Resolution Computed Tomographic Scan Features

Figure 1 Mucinous bronchioloalveolar cell carcinoma. Typical ‘‘lepidic’’ growth pattern: mucinous talQ9, columnar, Q9 mucin-producing neoplastic cells cover well preserved intraalveolar septa (hematoxylin-eosin, midpower).

nitis (DIP pattern).17 This patternQ5 is typical of epi- Q5 thelial tumors (especially adenocarcinoma) but it is also observed in lymphoproliferative disorders. Lymphangitic spread is characterized by tumor filling of septal and peribronchovascular lymphatics; blood vessels are often coexistently involved and nodular interstitial desmoplasia does occur, mostly in epithelial tumors.18 Lymphatics are evident and dilated only in lymphangitic spread due to epithelial neoplasms. Lymphangitic carcinomatosis (Fig. 2) is particularly common with carcinomas of the stomach, breast, lung, prostate, pancreas, and ovary. Lymphomas, myeloproliferative disorders, Kaposi sarcoma, and metastatic angiosarcoma may infiltrate or usually infiltrate the lung parenchyma following lymphatic routes. Hematogenous metastases commonly present as parenchymal nodules, eventually with central necrotic areas, favoring the mid- to lower and peripheral

Ground-glass attenuation, alveolar nodules, ‘‘crazy paving’’ pattern

Pneumonia-like/desquamative interstitial pneumonia pattern

Ground-glass attenuation, alveolar opacification

Lymphangitic

Reticular pattern;

Hematogenous

Nodules, randomly

Intravascular

Tree in bud pattern,

tree in bud pattern distributed mosaic oligemiaQ8,

Q8 Interstitial

pulmonary infarction Ground-glass attenuation; reticular pattern; crazy paving pattern

Cystic

Cysts nodules

Figure 2 Carcinomatous lymphangitis. Transbronchial lung biopsy: lymphatics around bronchiolovascular bundles and postcapillary venules are dilated and contain clusters of neoplastic cells (hematoxylin-eosin, low power).

535

536

Q6

Q10

SEMINARS IN RESPIRATORY AND CRITICAL CARE MEDICINE/VOLUME 28, NUMBER 5

lung fields. Pulmonary tumor thrombotic microangiopathy (with pulmonary hypertension, acute or subacute cor pulmonale) is a rare clinicopathological entity in which widespread tumor emboli (mainly from the stomach, breast, ovary, gallbladder, liver) along with fibrocellular intimal proliferation and thrombus formation in the small arteries and arterioles of the lung are the histological hallmarks.19Intravascular neoplastic growth patterns may involve mainly the capillary bed as typically observed in intravascular lymphomatosis.20 Interstitial interalveolar infiltration by tumor cells (interstitial pattern) may closely simulate interstitial inflammation; spindle cell carcinomas, mesenchymal tumors, and malignant thymoma, and lymphoproliferative disorders may present in areas in which the growing pattern is interstitial.15,21 Multiple cystic neoplastic lesions are due to metastatic squamous carcinoma, bronchioloalveolar cell carcinoma, or metastatic papillary tumors; rarely malignant cysts are observed in metastatic low-grade sarcomas,11 low-grade lymphomas, light chain deposition disease,9 and mesenchymalQ6 cystic hamartoma.11 Histopathological growth patterns have corresponding high-resolution computed tomographic (CT) scan features (Table 1).22,23 However, radiological findings, and sometimes the clinical profile, may also exhibit secondary changes: alveolar hemorrhage, mainly observed in cases of diffuse neoplastic interstitial infiltration or vascular thrombosis,24,25 organizing pneumonia, or eosinophilic pneumonia in the parenchyma surrounding the infiltrating tumor.21

BRONCHOALVEOLAR LAVAGE FLUID ANALYSIS: TECHNICAL KEY POINTS AND ADJUVANT TECHNIQUES BAL fluid should be processed with the understanding that it is always possible to detect neoplastic cells.26 Simple smears and centrifuged or Millipore-filtered preparations (Millipore, Billerica, MA) are routinely used. However, in recent years liquid-based cytology has emerged as an alternative to conventional cytopreparatory methods. In particular, the ThinPrep system (Cytyc Corporation, Marlborough, MA) has found broad acceptance. Most comparative studies have shown the ThinPrep system to perform as well as or better than conventional preparations in nongynecologic cytology; plus, the residual cells within the vial can be used for DNA analysis or immunohistochemical and other special studies.27 Besides May-Gru¨nwald-Giemsa or Diff-QuikQ10 staining methods, Papanicolaou stain should be used routinely for its value in detecting and defining neoplastic epithelial or mesenchymal cells. Diff Quick stain may be used for rapid on-site evaluation, a method already proposed to improve the yield of transbronchial needle aspiration. Preparation of cell blocks has been abandoned

2007

by many laboratories. The benefits of this technique (the recognition of histological patterns and the possibility to have unstained slides available for immunocytochemical investigations) are, however, still evident in fine needle aspiration samples, and they may also be appreciated in BAL fluid specimens.28 Application of immunocytochemistry permits the extension and expansion of morphology by means of increasingly more sensitive and specific markers that can be visualized in single cells. Thyroid transcription factor 1 (TTF-1) along with cytokeratin (CK) 7 and 20 is very helpful in the distinction of primary pulmonary adenocarcinomas from metastatic adenocarcinomas to the lung and mesothelioma; nuclear immunostaining for estrogen and progesterone receptors is usedQ11 to document lung Q11 involvement by breast carcinomas. Other markers (an incomplete list includes cytokeratins, vimentin, desmin, CD45, vascular markers -anti CD31 and CD34-Q12) Q12 may be helpful to distinguish between epithelial tumors and neoplasms of mesenchymal origin. A panel of antibodies directed to vimentin, S-100 protein, HMBQ13- Q13 45, and melanoma-associated antigen recognized by T cells (MART1) is used to establish a diagnosis of melanoma. The oldest markers ‘‘carcinoembryonic antigen (CEA), epithelial membrane antigen (EMA), monoclonal antibodies reacting with glycoprotein antigens –B72.3, Ca 19–9, Ca125, Ca15–3, CD15, MOC31, and BerEP4’’ need to be interpreted in the clinical context because they are identified in a variety of neoplastic as well as reactive nonneoplastic epithelial cells.28,29 The classification of most hemopoietic neoplasms is by a combination of antigen expression and morphology, chromosomal karyotype, and molecular genetics. Flow cytometry is essential for determination of antigen expression in this kind of tumor, allowing one to stain and correctly identify as many as 10 antibodies simultaneously.30 Molecular technologies are being used with increasing frequency in many areas of diagnostic cytopathology and in an ever-expanding series of research applications utilizing cytological samples. However, to date these techniques have a minor role in the daily practice as far as BAL fluid analysis is concerned.28

DIAGNOSTIC VALUE OF BRONCHOALVEOLAR LAVAGE IN LUNG MALIGNANCY Application of BAL to the diagnosis of pulmonary malignancy was first reported in the early and mid1980s,31–36 and the diagnostic role of this tool was confirmed a few years later in numerous articles.37–45 In immunocompromised patients, the diagnostic yield appeared to be less than 50%, and the cells identified were mostly of the hematologic lineage.32,33 Among the early


Q14

Q18 Q19

descriptions of primary lung cancer in BAL specimens were cases of bronchioloalveolar cell carcinoma,31,34 probably because of the diffuse pneumonia-like infiltrate with which this neoplasm may manifest. The distinction between localized tumors and diffuse processes was not apparent in the first reports.46HoweverQ14, later, in a prospective study to assess the value of the addition of BAL to the routine bronchoscopic exploration with bronchial washing and postbronchoscopy sputum procedures in the diagnosis of peripheral primary lung cancer not visible through bronchoscopy (39 nodules and 28 infiltrates) being fluoroscopic guidance was not available, de Garcia et al reported a diagnostic yield of 33% (18/55 patients).47 Wongsurakiat et al48 more recently reported a diagnostic yield of 47% in 55 patients with peripheral lesions on chest radiographs suspected for carcinoma. Eventually, fine needle aspiration biopsy earned the main diagnostic role in the diagnosis of peripheral tumors appearing as solitary nodules.49,50 BAL demonstrated and still shows its practical value in the diagnosis of disseminated or diffuse tumors51–53 (Table 2).

Epithelial Tumors The histotype was considered an important element to predict the diagnostic yield of BAL in epithelial tumors; adenocarcinoma and BAC are the two forms of tumor in which BAL has the highest diagnostic yield. However, the infiltrative patterns also appeared to be a good predictorQ18 being lymphangitic carcinomatosa and tumors with a lepidic growth pattern diagnosed by BAL in the majority of casesQ19. (83% and 93% of cases, res pectively, in the series reported by Poletti et al).52 Levy et al42 compared the yield of several diagnostic procedures applied to 12 patients with known malignancies (bladder, breast, colon, prostate, and lung) and radiographic evidence of lymphangitic carcinomatosa. Patients with nodular metastases or endobronchial lesions were excluded. BAL was positive in each of the five patients to which it was applied. Bronchial washings were positive Table 2 Diagnostic Yield in Diffuse Malignant Pulmonary Infiltrates52

Q15

Tumor Histotype

Yield

%

Adenocarcinoma

62

48

77

Bronchioloalveolar cell carcinoma

44

41

93

Squamous cell carcinoma

10

5

50

Small cell carcinoma Ductal breast carcinoma

4 10

3 8

75 80

Renal cell carcinoma

5

3

60

15

10

67

Hodgkin disease

9

3

33

AcuteQ16 myelogenous leukemia

1

1

MelanomaQ17

2

1

Non-Hodgkin lymphoma

Q16 Q17

n CasesQ15

537

in four of seven cases (57%), whereas brushings were positive in two of five cases (40%). Transbronchial lung biopsy was positive in four of nine cases (44%) but was the only positive specimen in one case (8%). The diagnostic yield of BAL remained high (66%) in a more recent paper in which pneumonia-like consolidation due to adenocarcinoma was documented by CT, a more sensitive tool compared with simple radiography.54BecauseQ20 adenocarcinoma (from the lung, Q20 breast, gastrointestinal tract, or pancreas) is the usual histological subtype in carcinomatous lymphangitis55 and BAC or adenocarcinoma, primary or metastatic, are usually the subtypes causing a lepidic growth pattern or ‘‘tumoral pneumonia’’15 it is clear that adenocarcinoma and BAC may be more easily identified by BAL. Cytological distinction between mucinous and nonmucinous, well-differentiated adenocarcinomas may be based on cytological specimens: in non-mucus-producing tumors variable numbers of well-demarcated rounded or papillary clusters of tumor cells are evident. These clusters are composed of overlapping small, round, or roughly cuboidal cancer cells with scant clear or lightly stained cytoplasm and moderately hyperchromatic nuclei with one or two small nucleoli. In the mucous-producing adenocarcinomas single cells as well as clusters are present. The tumor cells are larger and have abundant mucus-producing cytoplasm. The distinction between different subtypes of BAC and adenocarcinoma with papillary aspects is not feasible by cytology,5 (Fig. 3) although the presence of bland neoplastic cells in clusters, cells resembling alveolar macrophages, papillary fronds, occasional fibrovascular septa, depth of focus (three-dimensional clusters), nuclear pseudoinclusions, and, infrequently, psammoma bodies have been reported as peculiar cytological features of BAC. The expression of TTF-1 and surfactant proteins, and the epidermal growth factor receptor (EGFR) gene mutation that are now part of the diagnostic workup and therapeutic decision steps in subjects with these tumors may be documented on cytological preps56 (Fig. 4). In hematogenous metastases with a multinodular pattern the diagnostic yield was lower (45%),52 an expected result because, usually, tumor nodules are well demarcated from the surrounding parenchyma with a pushing border.15 The analysis of both aliquots (early or ‘‘bronchial’’ and late or ‘‘alveolar’’) seems to increase the diagnostic yield.43 Lymphocytosis or neutrophilic, eosinophilic, or mixed alveolitis may be observed in association with the presence of neoplastic cells.57,58 Adenocarcinoma of different subtypes or other common epithelial tumors (squamous, small cell carcinoma) may develop in diverse morphological and clinical settings: idiopathic pulmonary fibrosis, progressive systemic sclerosis, cystic pulmonary airway malformation, Hermansky-Pudlak syndrome.59–62 There are only anecdotal reports of the utility of BAL in the diagnosis of epithelial

538


2007

Figure 3 (A) Clusters of neoplastic cells with cytoplasm containing mucin in a case of mucinous bronchioloalveolar cell carcinoma (Papanicolaou stain). (B) A cluster of well-differentiated neoplastic cells; irregular nuclei with evident nucleoli are present. Papillary adenocarcinoma to the lung (Papanicolaou stain). (C) Three-dimensional cluster of uniform cells with round, slightly irregular nuclei, and small but distinct nucleoli (Diff-Quik stain): nonmucinous bronchioloalveolar cell carcinoma.

lung malignancy in this peculiar context62,63; two important elements that make cytological analysis of BAL fluid not highly specific and probably not sensitive are the presence of atypical reactive, but not frankly neoplastic, epithelial cells in fibrosing lung disorders64 and

Q21

Figure 4 Primary pulmonary adenocarcinoma. Neoplastic cells are well depicted by monoclonal antibodies against TTFQ21-1.

the fact that tumors are not always disseminated at the beginning.

Malignant Hematologic Disorders Pulmonary involvement due to malignant hematologic disorders is not a rare occurrence in patients with a lymph-node-based lymphoma; it is rarer as a clinical event in subjects with myeloid tumors.65,66 Primary pulmonary lymphoma occurs in a minority of subjects. The most common type of primary pulmonary lymphoma is extranodal marginal zone B cell lymphoma, which arises from bronchus-associated lymphoid tissue. It represents 70 to 90% of all primary pulmonary lymphomas, 3 to 4% of extranodal non-Hodgkin lymphomas (NHLs), and 0.5 to 1% of primary pulmonary malignancies.65 An association with collagen vascular diseases, mainly Sjo¨gren syndrome, common variable immunodeficiency, and human immunodeficiency virus (HIV) infection has been reported. The translocation t(11;18)(q21;q21), which results in a fusion of the cIAP2 region on chromosome 11q21 with the MALT1Q22 Q22 gene on chromosome 18q21 is documented in more


539

Figure 5 (A) Primary pulmonary B cell lymphoma-MALT type: centrocytic-like lymphocytes (Diff-Quik stain). (B) Primary pulmonary B cell lymphoma-MALT type: a plasma cell with intracytoplasmic vacuoles (Mott-like cell) along with lymphocytes and a mast cell (Diff-Quik stain).

Q23

Q24

than one third of cases.67 Interestingly, this translocation affects the nuclear factor kappa B (NF-kB) pathway. Lymphomatoid granulomatosis is an angiocentric and angiodestructive lymphoproliferative disease involving extranodal sites, consisting of Epstein-Barr virus (EBV)-positive cells admixed with reactive T cells, which usually numerically predominate. The lesion has a spectrum of histological grade and clinical aggressiveness that is related to the proportion of large B cells.65 The most common site of involvement is lung. The old series probably included cases of extranodal natural killer (NKQ23)/T cell lymphomas primary in the lungs were included. Diffuse large B cell lymphomas make up 10% of cases of primary pulmonary lymphomas.65 T cell lymphomas and Hodgkin disease rarely occur primarily in the lungs.68,69 BAL may contribute to the diagnosis in malignant lymphoproliferative disorders, either primary or secondary in the lungs.51 In NHL the BAL diagnostic yield reported was 67%.51 An increased total cell count due mainly to lymphocytosis is evident in the majority of cases. Neoplastic cells in indolent lymphomas of B cell type may have morphological features not easily distinguished from normal or ‘‘activated’’ lymphocytes or formQ24 dense aggregates of lymphocytes present in bronchial specimens of patients with follicular bronchitis/bronchiolitis.28 Cells with nuclear membrane irregularities and indentations, fine nuclear chromatin, inconspicuous nucleoli, and scant cytoplasm, monocytoid cells, lymphoplasmacytoid lymphocytes, and plasma cells with occasionally intranuclear inclusions known as Dutcher bodies may be observed, and their presence helps to suggest the diagnosis (Fig. 5). However the same morphological findings may be present in nonmalignant lymphoproliferative disorders such as lymphocytic interstitial pneumonia or diffuse Castleman diseases.65 In high-grade B cell lymphomas frankly malignant cells (large cleaved and noncleaved) are the

morphological clue for the diagnostic hypothesis; (Fig.Q25). In T cell lymphomas a spectrum of atypical Q25 cells with nuclei varying in shape and ranging from small to large, often with convoluted nuclei, have been described.51 However, in all these contexts, for a precise diagnostic report, immunocytochemistry and flow cytometry analysis are mandatory to define the cellular lineage; in B cell lymphomas the monoclonality is demonstrated only when a monotypic expression of light chains is evident70,71 (Fig. 6). Gene rearrangement analysis has been shown to be useful to document monoclonality of T cell lineage.72 B-lymphocyte clonality analysis in the setting of a clinical suspicion of both primary and secondary pulmonary lymphoma performed by polymerase chain reaction (PCR) demonstrated a 97% specificity and a 95% negative predictive value73 because a weak detectable B cell clonality in BAL fluid was observed in 14% of patients with nonlymphomatous

Figure 6 Primary pulmonary B cell lymphoma- mucosaassociated lymphoid tissueQ26 type. Flow cytometry show- Q26 ing a monoclonal expression of surface light chains (kappa chains).

540


2007

Figure 7 (A) Hodgkin lymphoma. One Reed-Sternberg cell showing a typical multilobed nucleus containing large nucleoli; scattered small lymphocytes are part of the inflammatory background (Diff-Quik stain). (B) Hodgkin lymphoma; cell block preparation. CD30 stain: a single mononuclear Hodgkin cell shows a paranuclear staining.

pulmonary lesions, notably autoimmune and chronic infectious diseases.73 The diagnostic yield of BAL in the diagnosis of parenchymal lung involvement due to Hodgkin disease38 is low (33%)51 mainly because diagnostic cells (Reed-Sternberg cells or Hodgkin cells) are scattered in an inflammatory background8 (Fig. 7A); lymphocytosis in BAL fluid was reported to be more evident in patients in which diagnostic cells were detectable.44 Reed-Sternberg cells or Hodgkin cells may be better characterized by immunocytochemistry (these cells are, among a variety of markers, positive for CD15, CD30) (Fig. 7B). BAL is useful in the diagnosis of pulmonary involvement due to chronic lymphocytic leukemia74 and in the differential diagnosis between chronic lymphocytic leukemia in the lung and mimickers such as sarcoidosis.75 Diagnosis of diffuse myelomatous pulmonary infiltration established by BAL demonstrating the presence of monoclonal plasma cells has been reported.76 Symptomatic leukemic infiltration of the lung is the least common cause of pulmonary infiltrates in patients with leukemia; only anecdotal reports confirm the BAL utility in the diagnosis of myeloid lung infiltration in these patients.35,77 Leukemic pulmonary infiltration causing respiratory failure in 20 % of cases as the first manifestation of acute monocytic leukemia has been reported7; in this context BAL was reported to be a very useful diagnostic tool.7 Because these patients usually have concomitant coagulopathies BAL recovery may be contaminated with blood; up to now there are no studies discussing the criteria useful to differentiate between peripheral blood myeloid cells contaminating BAL fluid and myeloid cells actually infiltrating the alveolar spaces.

Other Malignancies The reports presenting data on the utility of BAL to detect neoplastic cells from metastatic malignant melanoma and sarcomas are few.51,78 Metastases to the lungs

from sarcomas occur in patients in which the origin of the tumor is well known. However, the presence of metastases in the lungs due to melanoma in patients in which the history of the primary tumor is remote and forgotten or unknown is a clinical eventuality; cytological BAL features useful to address the correct diagnosis include a variable amount of melanin pigment in the cytoplasm of atypical cells (although in so-called amelanotic melanoma this pigment is absent) (Fig. 8), isolated or loosely cohesive groups of round to oval cells with eccentric nuclei, regular nuclear outlines, the presence of large intranuclear clear zones or ‘‘holes’’ (nuclear cytoplasmic inclusions) (Fig. 8), binucleation and multinucleation, fine chromatin pattern and prominent nucleoli; finally only immunocytochemistry documenting the positivity for HMBQ27-45, melanoma-associated Q27 antigen recognized by T cells (MART1), or SQ28-100 Q28 proteins confirms the origin of the tumor cells.28 In our experience BAL was useful to demonstrate diffuse lung infiltration due to epithelial-type malignant

Figure 8 Metastatic ‘‘amelanotic’’ melanoma. A single cell with a large nucleus and a nuclear pseudoinclusion: the cytoplasm does not contain pigment (Diff-Quik stain).


mesothelioma. The detection of human herpesvirus 8 (HHV8) DNA in BAL is restricted to patients with Kaposi sarcoma and is highly sensitive and specific for pulmonary involvement of Kaposi sarcoma.79

541

Table 3 Clinical Settings in Which Bronchoalveolar Lavage Findings May Improperly Suggest a Diagnosis of Epithelial Malignancy EPITHELIALQ29 ATYPIA SUGGESTING A DIAGNOSIS OF

Q29

ADENOCARCINOMA Diffuse alveolar damage of known cause (acute respiratory

ABNORMALITIES OF NONLYMPHOID CELLS IN BRONCHOALVEOLAR LAVAGE FLUID MIMICKING MALIGNANCIES In a variety of lung processes the pulmonary alveoli or the cystic airspaces are lined by one or more layers of small cuboidal or columnar cells that are in continuity with and identical or similar to the adjoining bronchioles.80 Furthermore, pneumocytes type II are highly reactive cells that respond to various pathological processes by morphological changes that may perfectly mimic adenocarcinoma or its precursor lesions in cytological samples81; viral infections mainly due to DNA viruses and drugs/radiation may induce on respiratory epithelium marked cellular enlargement associated with nuclear modification that may cause interpretive troubles. Finally, macrophages with large cytoplasmic vacuoles or abundant bubbly or lacy vacuolated cytoplasm characteristically observed in lipoidic pneumonia may be confused with mucus-producing cancer cells.28 In Table 3 the clinical settings in which BAL fluid analysis may present morphological findings suggesting an incorrect diagnosis of lung malignancy are reported. Linssen et al81 evaluated—only by means of MayGru¨nwald-Giemsa staining—the prevalence of reactive type II pneumocytes (RPII) in BAL fluid samples obtained from patients with various pulmonary disorders. RPII were generally large cells with a higher nuclear:cytoplasmic ratio and deeply blue-stained vacuolated cytoplasm. Most RPII occurred in cohesive cell groups, and vacuoles tended to be confluent. RPII were present in 22% of cases (94/433 samples), and the highest prevalence was noted in patients with systemic inflammatory response syndrome and alveolar hemorrhage. In addition, RPII tended to occur more frequently in ventilatorassociated pneumonia, Pneumocystis pneumonia, extrinsic allergic alveolitis, and drug-induced pulmonary disorders in virtually all cases with diffuse alveolar damage or honeycombing as the main morphological feature. In a study of BAL cytology specimens from a series of 38 patients with acute respiratory distress syndrome (in which the histopathological hallmark is diffuse alveolar damage), Stanley et al82 noted that RPII were transiently present during the early and organizing stages of the disease but did not persist after day 32 following onset of the illness; this temporal span and the clinical setting in which these cytological modifications may characterize BAL profile are per se useful criteria to exclude a diagnosis of malignancy. Furthermore, morphological features in BAL fluid of patients with diffuse alveolar damage have been well defined83: the slides are

distress syndrome, severe infections, drugs/radiationQ30,.......)

Q30

Diffuse alveolar damage of unknown cause (Hamman-Rich syndrome, acute exacerbation of idiopathic pulmonary fibrosis) Viral infections Organizing pneumonia Chronic lung processes with usual interstitial pneumonia as morphological background (idiopathic pulmonary fibrosis;Q31 asbestosis, collagen

Q31

vascular diseases, chronic hypersensitivity pneumonitis, chronic fibrosis due to drugs) Chronic pneumonias of varying etiology Pulmonary infarction EPITHELIAL ATYPIA WITH BIZARRE, EOSINOPHILIC CELLS SUGGESTING A DIAGNOSIS OF SQUAMOUS OR GIANT CELL CARCINOMA Radiation therapy Antineoplastic drugs Chronic thermal injury VACUOLATED MACROPHAGES MIMICKING MUCOUS ADENOCARCINOMA Lipoidic pneumonia Organizing pneumonia Amiodarone lung injury Metabolic disorders (Gaucher syndrome)

moderately to highly cellular with a large number of neutrophils andQ32 alveolar macrophages. The epithelial Q32 component, which may be depicted by monoclonal antibodies against cytokeratins, anti-B72.3 or antiTTFQ331, displays various degrees of nuclear atypia28,81; Q33 nuclei are large, round to oval, and hyperchromatic, and most have a single nucleolus and irregularities of nuclear contour. Some epithelial clusters are three-dimensional, with peripheral cells showing clear or vacuolated cytoplasm, protruding outward and resembling hobnails. Other aggregates appear two-dimensional, as sheets of cells with flattened and dense cytoplasm (squamotizedQ34). Both types of cell clusters may be associated Q34 with dense, basophilic, or amphophilic, amorphous extracellular material (the cytological counterpart of hyaline membranes) (Fig. 9A). This cytological pattern mimicking adenocarcinoma has also been recognized in cases of acute interstitial pneumonitis (Hamman-Rich syndrome),84 acute exacerbation of idiopathic interstitial pneumonitis (Fig. 9B),85 or along with a huge increase of eosinophils in acute eosinophilic pneumonia.86 Staining using monoclonal antibodies against cytokeratins may be

542


2007

Figure 9 (A) Patient with acute respiratory distress syndrome. A pseudopapillary structure with dysplastic reactive type II cells surrounding amorphous extracellular material (hyaline membrane) (Papanicolaou stain). (B) Patient with acute exacerbation of idiopathic pulmonary fibrosis. A cluster of reactive type II cells surrounds metachromatic extracellular material (Diff-Quik stain). (C) Patient with acute exacerbation of idiopathic pulmonary fibrosis. Dysplastic cells are positive for cytokeratins, demonstrating their epithelial nature (anticytokeratin staining).

Q35

useful to document the epithelial nature of these cells (Fig. 9C). Enlarged nuclei, prominent nucleoli, cytoplasmic keratinization, multinucleated bizarre cells indistinguishable from squamous carcinoma or from the uncommon giant cell carcinoma may be observed as an acute effect of irradiation or treatment including cyclophosphamide or other antiblastic drugs on respiratory epithelium.28,87 Chronic thermal injury may cause atypical squamous metaplasia of bronchial epithelium.28 Organizing pneumonia, cryptogenic, due to known causes, or observed in specific clinical contexts, presents a peculiar BAL profile.53,88 However, dysplastic type II cells that may be misinterpreted as neoplastic have been described in a minority of cases.88 Cytopathic modifications due to viral infections may be troublesome and the differential diagnosis between an infectious process and adenocarcinoma may result difficultQ35.28,53 Cluster of nonciliated cells with enlarged nuclei with prominent, occasionally irregular nucleoli accompanied by large single cells with prominent nucleoli may be observed. The presence of ciliocytophoria

(partial separation of the ciliated tuft from the nucleated portion of the cell or presence of anucleated tufts of cilia), and of typical inclusions ‘‘intranuclear (herpes simplex virus, adenovirus); nuclear and cytoplasmic (cytomegalovirus, measles infection); multiple eosinophilic cytoplasmic inclusions, and multiple deeply basophilic inclusion bodies with clear halos within the degenerated cytoplasm of the multinucleated syncytial giant cells (respectively, in parainfluenza and respiratory syncytial virus infections)’’ correctly indicate the diagnosis. Furthermore, viruses involved can be specifically identified in cells by immunocytochemistry with monoclonal antibodies and by in situ hybridization with c DNAQ36.28,89 Q36 In lipoidic pneumonia, inhaled oils cannot be absorbed and are phagocytizedQ37 by pulmonary macro- Q37 phages. The cytoplasm of the enlarged macrophages contains a great many vacuoles, giving it a characteristic lacy appearance. The nuclei are either single or multiple, small, and of normal appearance. Mucus-producing cancer cells, as a rule, display highly abnormal nuclei, and, furthermore, the cytoplasmic mucin in cancer cells is


Q39

Q38

Q40

Figure 10 Exogenous lipoidic pneumonia. A multivacuolated cell contains drops of positive oil red material. These drops are also evident outside the cytoplasm (oil red stain) (colorQ39 not shown).

almost invariably limited to a single vacuole; however, the definitive diagnosis is based on special stains in unfixed air-dried specimens demonstrating the presence of oil (oil red O, Sudan black)28,53 (Fig. 10). Rarely, crowded foamy macrophages, observed mainly in patients with organizing pneumonia and rarely in amiodarone toxicity and Gaucher syndrome, in which macrophages with small eccentric nuclei and abundant striated and finely vacuolated PASQ38 positive cytoplasm are detectable, may be, at a first glance, difficult to discern from welldifferentiated mucus-producing cancer cells. BIOMARKERS IN BRONCHOALVEOLAR LAVAGE FLUID AND ITS VALUE IN THE CLINICAL PRACTICE Screening programs, including CT, autofluorescent bronchoscopy, biopsies, and bronchial lavage (BL) and BAL collection, andQ40 breath condensate analysis, have been initiated with the specific goal of identifying markers for the early detection of cell lung cancer.2,90 Gene methylation in BL might help to detect central tumors, but for peripheral cancer detection CT was shown to remain crucial.91 Identification and quantification of exhaled volatile compounds seem to be useful as complementary tests for the early diagnosis of lung cancer92,93; however, all these tests are as yet only research projects and not useful in the daily clinical practice. REFERENCES 1. Poletti V, Chilosi M, Olivieri D. Diagnostic invasive procedures in diffuse infiltrative lung diseases. Respiration 2004;71:107–119

543

2. Libby DM, Smith JP, Altorki NK, Pasmantier MW, Yankelevitz D, Henschke CI. Managing the small nodule discovered by CT. Chest 2004;125:1522–1529 3. Dail DH. Metastases to and from the lung. In: Dail DH, Hammar SP, eds. Q41Pulmonary Pathology. New York: Q41 Springer-Verlag; 1994:1585–1615 4. Muller KM, Respondek M. Pulmonary metastases: pathologic anatomy. Lung 1990;168(s):1137–1144Q42 Q42 5. Travis WD, Garg K, Franklin WA, et al. Evolving concepts in the pathology and computed tomography imaging of lung adenocarcinoma and bronchioloalveolar carcinoma. J Clin Oncol 2005;23:3279–3287 6. Jacobs JA, De Brauwer EI, Ramsay G, et al. Detection of non-infectious conditions mimicking pneumonia in the intensive care setting: usefulness of bronchoalveolar fluid cytology. Respir Med 1999;93:571–578 7. Azoulay E, Fieux F, Moreau D, et al. Acute monocytic leukemia presenting as acute respiratory failure. Am J Respir Crit Care Med 2003;167:1329–1333 8. Chilosi M, Zinzani PL, Poletti V. Lymphoproliferative lung disorders. Semin Respir Crit Care Med 2005;26:490–501 9. Colombat M, Stern M, Groussard O, et al. Pulmonary cystic disorder related to light chain deposition disease. Am J Respir Crit Care Med 2006;173:777–780 10. Yi ES. Tumors of the pulmonary vasculature. Cardiol Clin 2004;22:431–440 11. Aubry MC, Myers JL, Colby TV, Leslie KO, Tazelaar HD. Endometrial stromal sarcoma metastatic to the lung: a detailed analysis of 16 patients. Am J Surg Pathol 2002;26: 440–449 12. Mark EJ. Mesenchymal cystic hamartoma of the lung. N Engl J Med 1986;315:1255–1259 13. Poletti V, Casadei G, Boaron M, et al. Epithelioid haemangioendothelioma of the lung imitating clinical features of pulmonary histiocytosis X. Monaldi Arch Chest Dis 1997;52:346–348 14. Travis WD, Brambilla E, Muller-Hermelink HK, et al. Pathology and Genetics: Tumours of the Lung, Pleura, Thymus and Heart. Lyon: IARC; 2004 15. Colby TV, Koss MN, Travis WD. Tumors of the Lower Respiratory Tract. Washington, DC: Armed Forces Institute of Pathology; 1995. Armed Forces Institute of Pathology Fascicle, Third Series 16. Nind NR, Attanoos RL, Gibbs AR. Unusual intraparenchymal growth patterns of malignant pleural mesothelioma. Histopathology 2003;42:150–155 17. Mutton AE, Hasleton PS, Curry A, et al. Differentiation of desquamative interstitial pneumonia (DIP) from pulmonary adenocarcinoma by immunocytochemistry. Histopathology 1998;33:129–135 18. Janower ML, Blennerhassett JB. Lymphangitic spread of metastatic cancer to the lung: a radiologic-pathologic classification. Radiology 1971;101:267–273 19. Roberts KE, Hamele-Bena D, Saqi A, Stein CA, Cole RP. Pulmonary tumor embolism: a review of the literature. Am J Med 2003;115:228–232 20. Ko YH, Han JH, Go JH, et al. Intravascular lymphomatosis: a clinicopathological study of two cases presenting as an interstitial lung disease. Histopathology 1997;31:555– 562 21. Colby TV. Malignancies in the lung and pleura mimicking benign processes. Semin Diagn Pathol 1995;12:30– 44

544 Q43

Q44 Q45

Q46 Q47 Q48

Q49


22. Webb WR. Thin-section of the secondary pulmonary lobule: anatomy and the imageQ43. The 2004 Fleischner Lecture. Radiology 2006;239:322–338 23. Han D, Lee S, Franquet T, et al. Thrombotic and nonthrombotic pulmonary artery embolism: spectrum of imaging findings. Radiographics 2003;23:1521–1539 24. Shintaku M, Hwang MH, Amitani R. Primary choriocarcinoma of the lung manifesting as diffuse alveolar damage. Arch Pathol Lab Med 2006;130:540–543 25. Ebi N, Yamamoto H, Sakai J, Sugahara K, Arimura H, Nakanishi K. Angiosarcoma of the heart presenting as fatal pulmonary hemorrhage. Intern Med 1997;36:191–193 26. Technical recommendations and guidelines for bronchoalveolar lavage (BAL). Report of the European Society of Pneumology Task Group. Eur Respir J 1989;6:561–585Q44Q45 27. Linder J. Recent advances in thin-layer cytology. Diagn Cytopathol 1998;18:24–32 28. Koss GL, Melamed MR, eds. Koss’ Diagnostic Cytology. Philadelphia: Lippincott Williams & Wilkins; 2006 29. Grotte D, Stanley MW, Swanson PE, Henry-Stanley MJ, Davies S. Reactive type II pneumocytes in bronchoalveolar lavage fluid from adult respiratory distress syndrome can be mistaken for cells of adenocarcinoma. Diagn Cytopathol 1990;6:317–322 30. Orfao A, Lo’pez A, Flores J, et al. Diagnosis of hematological malignancies: new applications for flow cytometry. Hematology 2006;2:6–13 (EHAQ46 Educ Program)Q47 31. Springmeyer SC, Hackman R, Carlson JJ, et al. Bronchoalveolar cell carcinoma diagnosed by bronchoalveolar lavage. Chest 1983;83:378–379Q48 32. Stover DE, Zaman MB, Hajdu SI, Lange M, Gold J, Armstrong D. Bronchoalveolar lavage in the diagnosis of diffuse pulmonary infiltrates in the immunosuppressed host. Ann Intern Med 1984;101:1–7 33. Young JA, Hopkin JM, Cuthberston WP. Pulmonary infiltrates in immunocompromised patients: diagnosis by cytological examination of bronchoalveolar lavage fluid. J Clin Pathol 1984;37:390–397 34. Sestini P, Rottoli L, Gotti G, et al. Bronchoalveolar lavage diagnosis of bronchioloalveolar carcinoma. Eur J Respir Dis 1985;66:55–58 35. Rossi GA, Balbi B, Risso M, Repetto M, Ravazzoni C. Acute myelomonocytic leukemia: demonstration of pulmonary involvement by bronchoalveolar lavage. Chest 1985;87: 259–260 36. Weynants P, Cordier JF, Chapuis Collier C, et al. Primary immunocytoma of the lung: the diagnostic value of bronchoalveolar lavage. Thorax 1985;40:542–543 37. Linder J, Radio SJ, Robbins RA, et al. Bronchoalveolar lavage in the cytologic diagnosis of carcinoma of the lung. Acta Cytol 1987;31:796–801 38. Morales FM, Matthews JI. Diagnosis of parenchymal Hodgkin’s disease using bronchoalveolar lavage. Chest 1987;91:785–787 39. Davis WB, Gadek JE. Detection of pulmonary lymphoma by bronchoalveolar lavage. Chest 1987;91:787–790 40. Oka M, Kawano K, Kanda T, et al. Bronchoalveolar lavage in primary pulmonary lymphoma with monoclonal gammopathy. Am Rev Respir Dis 1988;137:957–959 41. Poletti V, Patelli M, Poggi S, Bertanti T, Spiga L, Ferracini R. Transbronchial lung biopsy and bronchoalveolar lavage in diagnosis of diffuse infiltrative lung diseases. Respiration 1988;54(s):66–72Q49

2007

42. Levy H, Horak DA, Lewis MI. The value of bronchial washing and bronchoalveolar lavage in the diagnosis of lymphangitic carcinomatosis. Chest 1988;94:1028–1030 43. Radio SJ, Rennard SI, Kessinger A, et al. Breast carcinoma in bronchoalveolar lavage: a cytologic and immunohistochemical study. Arch Pathol Lab Med 1989;113:333–336 44. Wisecarver J, Ness MJ, Rennard SI, Thompson AB, Armitage JO, Linder L. Bronchoalveolar lavage in the assessment of pulmonary Hodgkin disease. Acta Cytol 1989;33:527–532 45. Rennard SI, Albera C, Carratu L, et al. Clinical guidelines and indications for bronchoalveolar lavage (BAL): pulmonary malignancies. Eur Respir J 1990;8:956–969Q50 46. Pirozynki M. Bronchoalveolar lavage in the diagnosis of peripheral, primary lung cancer. Chest 1992;102:372– 374Q51 47. de Garcia J, Braco C, Miravitlles M, et al. Diagnostic value of bronchoalveolar lavage in peripheral lung cancer. Am Rev Respir Dis 1993;147:649–652Q52 48. Wongsurakiat P, Wongbunnate S, Dejsomritrutai W, et al. Diagnostic value of bronchoalveolar lavage and postbronchoscopic sputum cytology in peripheral lung cancer. Respirology 1998;3:131–137 49. Gasparini S, Ferretti M, Secchi EB, Baldelli S, Zuccatosta L, Guselli P. Integration of transbronchial and percutaneous approach in the diagnosis of peripheral pulmonary nodules or masses: experience with 1,027 consecutive cases. Chest 1995; 108:131–137 50. Clark BD, Vezza PR, Copeland C, Wilder AM, Abati A. Diagnostic sensitivity of bronchoalveolar versus lung fine needle aspirate. Mod Pathol 2002;15:1259–1265 51. Semenzato G, Poletti V. Bronchoalveolar lavage in lung cancer. Respiration 1992;59(s):44–46Q53 52. Poletti V, Romagna M, Allen KA, Gasponi A, Spiga L. Bronchoalveolar lavage in the diagnosis of disseminated lung tumors. Acta Cytol 1995;39:472–477 53. Costabel U. Atlas of Bronchoalveolar Lavage. London: Chapman & Hall Medical; 1998:41–46 54. Wislez M, Massiani MA, Melleron B, et al. Clinical characteristics of pneumonic-type adenocarcinoma of the lung. Chest 2003;123:1868–1877 55. Yang SP, Lin CC. Lymphangitic carcinomatosis of the lungs: the clinical significance of its roentgenologic classification. Chest 1972;62:170–187Q54 56. Subramanian J, Govindan R. Lung cancer in never smokers: a review. J Clin Oncol 2007;25:561–570 57. Lower EE, Baughman RP. Pulmonary lymphangitic metastasis from breast cancer: lymphocytic alveolitis is associated with favorable prognosis. Chest 1992;102:1113–1117 58. Bellocq A, Antoine M, Flahault A, et al. Neutrophil alveolitis in bronchioloalveolar carcinoma: induction by tumor-derived interleukin-8 and relation to clinical outcome. Am J Pathol 1998;152:83–92 59. Aubry MC, Myers JL, Douglas WW, et al. Primary pulmonary carcinoma in patients with idiopathic pulmonary fibrosis. Mayo Clin Proc 2002;77:763–770 60. Yang Y, Fujita J, Tokuda M, Bandoh S, Ishida T. Lung cancer associated with several connective tissue diseases: with a review of literature. Rheumatol Int 2001;21:106–111 61. Ioachimescu OC, Metha AC. From cystic pulmonary airway malformation, to bronchioloalveolar carcinoma and adenocarcinoma of the lung. Eur Respir J 2005;26:1181– 1187

Q50 Q51 Q52

Q53

Q54


Q55

Q56

Q57 Q58

62. Takahashi K, Ishida T, Ogura G, et al. Diagnostic usefulness of bronchoalveolar lavage in Hermanski-Pudlak syndrome: a case with double lung cancers. Intern Med 2004;43:972– 976 63. Biyoudi-Vouenze R, Tazi A, Hance AJ, Chastre J, Basset F, Soler P. Abnormal epithelial cells recovered by bronchoalveolar lavage: are they malignant? Am Rev Respir Dis 1990; 142:686–690 64. Chilosi M, Zamo` A, Doglioni C, et al. Migratory marker expression in fibroblast foci of idiopathic pulmonary fibrosis. Respir Res 2006;7:95Q55 65. Chilosi M, Zinzani PL, Poletti V. Lymphoproliferative lung disorders. Semin Respir Crit Care Med 2005;26:490– 501 66. Koh TT, Colby TV, Muller NL. Myeloid leukemias and lung involvement. Semin Respir Crit Care Med 2005;005: 514–519Q56 67. Bertoni F, Zucca E. Delving deeper into MALT lymphoma biology. J Clin Invest 2006;116:22–26 68. Sverzellati N, Poletti V, Chilosi M, Casoni G, Hansell D, Zompatori M. The crazy paving pattern in granulomatous mycosis fungoides: high resolution computer tomographypathological correlation. J Comput Assist Tomogr 2006;30: 843–845 69. Chetty R, Slavin JL, O’Leary JJ, Ansari NA, Gatter KC. Primary Hodgkin’s disease of the lung. Pathology 1995;27: 111–114 70. Zinzani PL, Tani M, Gabriele A, et al. Extranodal marginal zone B-cell lymphoma of MALT-type of the lung: singlecenter experience with 12 patients. Leuk Lymphoma 2003; 44:821–824 71. Poletti V, Romagna M, Gaspoini A, Baruzzi G, Allen KA. Bronchoalveolar lavage in the diagnosis of low-grade, MALT type, B-cell lymphoma in the lung. Monaldi Arch Chest Dis 1995;50:191–194 72. Keicho N, Oka T, Takeuchi K, Yamane A, Yazaki Y, Yotsumoto H. Detection of lymphomatous involvement of the lung by bronchoalveolar lavage: application of immunophenotypic and gene rearrangement analysis. Chest 1994; 105:458–462 73. Zompi S, Couderc LJ, Cadranel J, et al. Clonality analysis of alveolar B lymphocytes contributes to the diagnostic strategy in clinical suspicion of pulmonary lymphoma. Blood 2004; 103:3208–3215 74. Trisolini R, Lazzari Agli L, Poletti V. Bronchiolocentric pulmonary involvement due to chronic lymphocytic leukaemia. Haematologica 2000;865:1097Q57Q58 75. Marrucchella A, Epis R, Camerone G, Tondini M. Association between chronic lymphocytic leukaemia and sarcoidosis: clinical value of bronchoalveolar lavage. Sarcoidosis Vasc Diffuse Lung Dis 1999;16:101–103 76. Kamble R, Rosenzweig T. Diffuse pulmonary parenchymal involvement in multiple myeloma: antemortem diagnosis. Int J Hematol 2006;83:259–261 77. Kovalski R, Hansen-Flaschen J, Lodato RF, Pietra GG. Localized leukemic pulmonary infiltrates: diagnosis by

78. 79.

80.

81.

82.

83.

84.

85.

86.

87.

88.

89.

90.

91.

92.

93.

bronchoscopy and resolution with therapy. Chest 1990;97: 674–678 Linder J, Rennard SI. Bronchoalveolar Lavage. Chicago: American Society of Clinical Pathologists Press; 1988 Tam M, Reichenberger TM, McGandy CE, et al. Diagnosis of pulmonary Kaposi’s sarcoma by detection of human herpes virus 8 in bronchoalveolar lavage. Am J Respir Crit Care Med 1998;157:458–463Q59 Chilosi M, Poletti V, Murer B, et al. Abnormal reepithelizationQ60 and lung remodeling in idiopathic pulmonary fibrosis: the role of deltaN-p63. Lab Invest 2002;82: 1335–1345 Linssen KC, Jacobs JA, Poletti V, et al. Reactive type II pneumocytes in bronchoalveolar lavage fluid. Acta Cytol 2004;48:497–504 Stanley MW, Henry-Stanley MJ, Gajl-Peczalska KJ, Bitterman PB. Hyperplasia of type II pneumocytes in acute lung injury. Am J Clin Pathol 1992;97:669–677 Beskow CO, Drachenberg CB, Bourquin PM, et al. Diffuse alveolar damage: morphologic features in bronchoalveolar lavage fluid. Acta Cytol 2000;44:640–646 Bonaccorsi A, Cancellieri A, Chilosi M, et al. Acute interstitial pneumonia: report of a series. Eur Respir J 2003;21:187–191 Ambrosini V, Cancellieri A, Chilosi M, et al. Acute exacerbation of idiopathic pulmonary fibrosis: report of a series. Eur Respir J 2003;22:821–826 Trisolini R, Cancellieri A, Bonaccorsi A, Poletti V. Bronchoalveolar lavage suggesting diffuse alveolar damage in a patient with acute eosinophilic pneumonia. Sarcoidosis Vasc Diffuse Lung Dis 2001;18:311–312 Walzer T, Mukerjee D, Levine TS. Bronchial eoithelialQ61 atypia mimicking squamous cell carcinoma secondary to cyclophosphamide therapy. Cytopathology 2002;13:330– 332Q62 Cazzato S, Zompatori M, Baruzzi G, et al. Bronchiolitis obliterans-organizing pneumonia: an Italian experience. Respir Med 2000;94:702–708 Masih AS, Woods GL, Thiele GM, et al. Detection of cytomegalovirus in bronchoalveolar lavage: a comparison of techniques. Mod Pathol 1991;4:108–112 Greenwald P. A favourable view: progress in cancer prevention and screening. Recent Results Cancer Res 2007; 174:3–17 de Fraipont F, Moro-Sibilot D, Michelland S, Brambilla E, Brambilla C, Favrot MC. Promoter methylation of genes in bronchial lavages: a marker for early diagnosis of primary and relapsing non-small cell lung cancer? Lung Cancer 2005; 50:199–209 Philips M, Cataneo RN, Cummin AR, et al. Detection of lung cancer with volatile markers in the breath. Chest 2003;123:2115–2123Q63 Poli D, Carbognani P, Corradi M, et al. Exhaled volatile organic compounds in patients with non-small cell lung cancer: cross sectional and nested short-term follow-up study. Respir Res 2005;6:71–80

545

Q59 Q60

Q61 Q62

Q63

Author Query Form (SRCCM/00539) Special Instructions: Author please write responses to queries directly on proofs and then return back. Q1: All authors MDs? Q2: Please check correctness of affiliations. Q3: MALT okay as spelled out? Q4: changed as meant? or text missing? Q5: by ‘‘This’’ are you referring to the DIP pattern? if so, please say ‘‘This latter pattern’’; if not, please clarify Q6: changed as meant? If not, please reword for sense. Q7: Permission needed to reproduce any of the Tables? Q8: Dorland’s prefers hypovolemia. Please check and fix if needed Q9: okay as is? Q10: please check spelling and hyphenation of this brand name and provide the manufacturer and location. Q11: changed as meant? if not, please reword for sense. Q12: please fix placement of hyphens. Q13: please spell out HMB first use Q14: This sentence is so long as to be inaccessible. Please reword to simplify or divide. Q15: is the word Cases necessary here? or simply n? Q16: should there be a value of 100 in the percent column? Q17: should there be a value of 50 in the percent column? Q18: please reword this sentence hereafter for sense. Q19: does the period belong here? Q20: please reword for sense and clarity. Q21: please spell out TTF if possible Q22: if this is being used as a gene name, please italicize here and in all occurrences, including in refs. Q23: NK spelled out okay? Q24: do you mean ‘‘from’’ Q25: Which Figure does this refer to? Q26: (MALT spelled out okay? Q27: please spell out HMB first use Q28: Please spell out S first use. Q29: OK to remove asterisks (were they representing bullets? if so, not needed to connote hierarchy) Q30: Are you adding material in here? Q31: change semicolon to comma? or something missing?

Q32: changed as meant? or were other list items missing? Q33: please spell out B and TTF if possible Q34: not in Dorland’s. Please check spelling. Q35: please fix wording Q36: okay as is? spell out c? Q37: do you mean phagocytosed? Please fix as needed Q38: please spell out Q39: Edit of legend OK? Q40: okay to insert ‘‘and’’ here? or something else missing? Q41: these are editors, correct? Q42: what does (s) represent? (Suppl)? Please delete or fix as needed. Q43: is title complete? Q44: Is the Task Group the author? Q45: Medline indexes "Eur Respir J" but cannot find a listing for the reference 26 "Technical recommendations and guidelines for, 1989". Please check the reference for accuracy. Q46: The reference has no authors. Please proof carefully. (in reference 26 "Technical recommendations and guidelines for, 1989"(. Q47: Medline indexes "Hematology" but cannot find a listing for the reference 30 "Orfao, Lo’pez, Flores, et al, 2006". Please check the reference for accuracy. Q48: Medline indexes "Chest" but cannot find a listing for the reference 31 "Springmeyer, Hackman, Carlson, et al, 1983". Please check the reference for accuracy. Q49: what does (s) stand for? (Suppl)? please fix as needed Q50: Medline indexes "Eur Respir J" but cannot find a listing for the reference 45 "Rennard, Albera, Carratu, et al, 1990". Please check the reference for accuracy. Q51: Medline reports the first author "Pirozynki M" is not correct in the reference 46 "Pirozynki, 1992". Q52: Medline reports the first author "de Garcia J" is not correct in the reference 47 "de Garcia, Braco, Miravitlles, et al, 1993". Q53: What is (s)? please fix as needed Q54: Medline reports the first author "Yang SP" is not correct in the reference 55 "Yang, Lin, 1972". Q55: Reference has only first page number. Please provide the last page number if article is longer than one page. (in reference 64 "Chilosi, Zamo`, Doglioni, et al, 2006"). Q56: Please check year and fix vol. no. Q57: Medline indexes "Haematologica" but cannot find a listing for the reference 74 "Trisolini, Lazzari Agli, Poletti, 2000". Please check the reference for accuracy. Q58: Reference has only first page number. Please provide the last page number if article is longer than one page. (in reference 74 "Trisolini, Lazzari Agli, Poletti, 2000"). Q59: Medline reports the first author "Tam M" is not correct in the reference 79 "Tam, Reichenberger, McGandy, et al, 1998". Q60: as spelled in original? please check and fix

Q61: epithelial? endothelial? Please fix Q62: Medline reports the first author "Walzer T" is not correct in the reference 87 "Walzer, Mukerjee, Levine, 2002". Q63: Medline reports the first author "Philips M" is not correct in the reference 92 "Philips, Cataneo, Cummin, et al, 2003".

Instructions to Contributors Dear Contributor: Enclosed in this document please find the page proofs, copyright transfer agreement (CTA), and offprint order form for your article in the Seminars in Respiratory and Critical Care Medicine, Volume 28, Number 5, 2007. Please print this document and complete and return the CTA and offprint form, along with corrected proofs, within 72 hours. 1)

Please read proofs carefully for typographical and factual errors only; mark corrections in the margins of the proofs in pencil. Answer (on the proofs) all editor’s queries written in the margins of the proofs. Check references for accuracy. Please check on the bottom of the 1st page of your article that your titles and affiliations are correct. Avoid elective changes, as these are costly and time consuming and will be made at the publisher’s discretion.

2)

Please pay particular attention to the proper placement of figures, tables, and legends. Please provide copies of any formal letters of permission that you have obtained.

3)

Please return the corrected proofs, signed copyright transfer agreement, and your offprint order form, with the black and white or color prints of figures, if you received any.

4)

As a contributor to this journal you will receive one copy of the journal, at no charge. • If you wish to order offprints, please circle the quantity required (left column) and the number of pages in your article. If you wish to order additional copies of the journal please enter the number of copies on the indicated line. • If you do not want to order offprints or journals simply put a slash through the form, but please return the form.

Please send all materials back via overnight mail, within 72 hours of receipt, to:

Anita Kaufman Thieme Medical Publishers 333 Seventh Avenue, 5th Floor New York, NY 10001 Phone: 212-584-4694 Fax: 212-584-4681 E-mail: [email protected]

Please do not return your materials to the editor, or the compositor. Please note: Due to a tight schedule, if the publisher does not receive the return of your article within 7 days of the mail date (from the compositor), the publisher reserves the right to proceed with publication without author changes. Such proofs will be proofread by the editor and the publisher. Thank you for your contribution to this journal. Anita Kaufman, Production Editor, Journal Production Department Thieme Medical Publishers, Inc.

Thieme Medical Publishers, Inc. (the “Publisher”) will be pleased to publish your article (the “Work”) entitled _____________________________ in the Seminars in Respiratory and Critical Care Medicine, Volume 28, Number 5, 2007. The undersigned Author(s) hereby assigns to the Publisher all rights to the Work of any kind, including those rights protected by the United States Copyright laws. The Author(s) will be given permission by the Publisher, upon written request, to use all or part of the Work for scholarly or academic purposes, provided lawful copyright notice is given. If the Work, subsequent to publication, cannot be reproduced and delivered to the Author(s) by the publisher within 60 days of a written request, the Author(s) is given permission to reprint the Work without further request. The Publisher may grant third parties permission to reproduce all or part of the Work. The Author(s) will be notified as a matter of courtesy, not as a matter of contract. Lawful notice of copyright always will be given. Check appropriate box below and affix signature. [ ] I Sign for and accept responsibility for transferring copyright of this article to Thieme Medical Publishers, Inc. on behalf of any and all authors. Author’s full name, degrees, professional title, affiliation, and complete address: __________________________________

____________________________

Author’s printed name, degrees

Professional title

Complete professional address

______________________________

___________________

Author’s signature

Date

[ ] I prepared this article as part of my official duties as an employee of the United States Federal Government. Therefore, I am unable to transfer rights to Thieme Medical Publishers, Inc. ______________________________

_________________

Author’s signature

Date

Order Form for Offprints and additional copies of the Seminars in Respiratory and Critical Care Medicine (Effective October 2005) Please circle the cost of the quantity/page count you require (orders must be in increments of 100)

Quantity 100 200 300 400 500 1000

1 to 4 $198 $277 $356 $396 $446 $792

Pages in Article/Cost 5 to 8 9 to 12 $317 $440 $444 $615 $570 $791 $634 $879 $713 $989 $1,267 $1,758

Volume/Issue #:

13 to 16 $578 $809 $1,041 $1,156 $1,301 $2,313

17 to 20 $693 $970 $1,247 $1,386 $1,559 $2,772

Page Range (of your article):

Article Title: MC/Visa/AmEx No:

Exp. Date:

Signature: Name: Address: City/State/Zip/Country: Corresponding author will receive one complimentary copy of the issue in which the manuscript is published. Number of additional copies of the journal, at the discounted rate of $20.00 each: Notes 1. The above costs are valid only for orders received before publication of the issue. Please return the completed form, even if your institution intends to send a Purchase Order (the P.O. may sometimes be supplied after the issue has been printed).

2. Orders from outside the U.S. must be accompanied by payment. 3. A shipping charge will be added to the above costs. 4. Reprints are printed on the same coated paper as the journal and side-stapled. 5. For larger quantities or late orders, please contact reprints dept.

Phone: +1(212) 584-4662 Fax: +1(212) 947-1112 E-mail: [email protected]

As an added benefit to all contributing authors, a discount is offered on all Thieme books. See below for details or go to www.thieme.com

As a Thieme author you are entitled to a 25% discount for new books and a 35% discount for forthcoming books. We selected two books that might be of interest for you:

new!

25%

forthcoming!

Thurlbeck's Pathology of the Lung

Teaching Atlas of Chest Imaging

rd

3 Edition

Mark S. Parker, M.D.

Andrew M. Churg, M.D. Ph. D.

Associate Professor, Department of Radiology, Medical College of Virginia Hospitals-Virginia Commonwealth University, Richmond, VA, USA

Professor of Pathology, University of British Columbia; Pathologist, Vancouver Hospital & Health Sciences Center, Vancouver, BC, Canada Thurlbeck's cornerstone textbook and reference on pulmonary pathology returns in a brand new edition! Updated with the latest advances in the field, you will save time with all-inclusive coverage of neoplastic, non-neoplastic, infectious, occupational/environmental, and developmental pathologies in one book, learn how molecular biology provides a greater understanding of lung development, gain new insights into the diagnosis of neoplastic and non-neoplastic lung disease, find pertinent information on clinical features, epidemiology, and pathogenetic mechanisms of lung disease and much more! Comprehensive in its scope and authoritative in its scholarship, Thurlbeck's Pathology of the Lung is a virtual one-volume encyclopedia written by a ''who's who'' list of specialists. It is the one text that no pathologist, pulmonologist, or resident in either specialty can afford to be without.

$187.46

$249.95

2005, app.1032 pp., app.1064 illus., hardcover ISBN 1-58890-288-9

35%

Covering the entire venous and body circulation as examined by vascular ultrasound, this unique text/atlas is invaluable for diagnosing arterial and venous disease. It includes comprehensive chapters on vascular ultrasonography in the arteries and veins of the cerebral circulation and the peripheral upper and lower limb circulation, systematic coverage of all available ultrasound technologies, including continuous and pulsed-wave Doppler mode, b-mode, and conventional and color-coded duplex analysis in frequency and amplitude power modes, anatomy and physiology, normal and abnormal findings, test accuracy and sensitivity, pitfalls, and comparison with other diagnostic tests in each vascular region and special, difficult-to-interpret cases discussed in a separate section 2006, 792 pp., 1064 illus., hardcover, ISBN 1-58890-230-7

If you want to view more Thieme books, fell free to visit

$149.95

$97.47

Thieme Books

Thieme Author order form For faster service, call TOLL-FREE 1-800-782-3488 or fax this order form to 212-947-1112

Quantity

ISBN (last 4-digits only)

Author/Title

Price

Subtotal: Shipping & Handling (Add $7.50 for the first book and $1.00 for each additional book): NY and PA residents add applicable sales tax:

TOTAL: Enclosed is my check for $____________________ Charge my:

AMEX

MasterCard

VISA

Discover

Card#________________________________________________________________Exp._______________________________________________________ First Name_________________________________ MI ________________________Last Name__________________________________________________ Address_________________________________________________________________________________________________________________________ City/State/Zip_____________________________________________________________________________________________________________________ Telephone____________________________________________________________FAX________________________________________________________ e-mail___________________________________________________________________________________________________________________________ Signature________________________________________________________________________________________________________________________ EM1-05