Cytopathology-8 DR. MAHA AL-SEDIK

Sputum , bronchial wash and bronchial brush cytology

Objectives: 1- introduction. 2- Safety in work. 3- Role of cytology in respiratory disease. 4- Cytological sample methods. 5- Sputum. 6- Hemoptysis 7- Importance of sputum culture. 8- Sputum collection and processing. 9- Bronchial washing. 10- Bronchial brushing.

Introduction: Cytological examination of specimens obtained from the respiratory tract is a primary and frequently the initial diagnostic technique performed in patients with respiratory symptoms or in those presenting with a pulmonary abnormality. Due to the complexity of the respiratory tract and the location of various target lesions, a variety of cytological techniques have been developed for the study of diseases involving the respiratory system.

Safety at Work: Laboratory staff processing pulmonary cytological materials are at particular risk of exposure to aerosol infections. They must protect themselves from this potential hazard by wearing protective masks and gloves during dealing with the samples, and following standard laboratory hygienic procedures.

Role of cytology in respiratory disease Major role: Diagnosis of malignant neoplasms involving lung both primary and metastatic. Minor role: Specific inflammatory process. Benign neoplasms.

Cytological Sampling Methods in respiratory system: Sputum: from a spontaneous deep cough, obtained on arising in the morning. Bronchial Brushings: using bronchoscope. Bronchial Washings: using bronchoscope.

Sputum It is a mucous layer that covers the airways and protects bronchial epithelium against inhaled noxious substances. Sputum is a mucous substance that is secreted into the airways of the respiratory tract (lungs ,bronchi, trachea) and can be coughed up, spit out or swallowed. It is produced by surface epithelial cells and sub mucous glands.

Sputum Cytology The spontaneous production of significant amounts of sputum often indicates pulmonary disease. Sputum is composed predominantly of mucoid substances, and variable numbers of inflammatory and epithelial cells. Variations in the numbers of macrophages, neutrophils, and epithelial cells and morphologic alterations in the latter elements can yield significant insight into the underlying pathologic process.

5 CELLS 3 FOOD Chemical composition: 95% water 5 % organic components: Squamous epithelial cells. Respiratory epithelial cells. Polymorphonuclear leukocytes. Mononuclear cells. Alveolar macrophages. Carbohydrates ( such as sialic acid which contribute to its high viscosity). Proteins ( enzymes, immunoglobulins), glycoproteins. Lipids. 5 CELLS 3 FOOD

Abnormality of sputum: Normal sputum is either white or colorless. Yellow to green sputum can be an indication of pus, infection such as pneumonia. Blood in sputum is called hemoptysis which could be due to e.g. ; lung cancer, tuberculosis, lung abscess , hemorrhage. Parasites in sputum can occur as in ascaris.

Hemoptysis: The expectoration (coughing up) of blood or of blood stained sputum .

Common causes of hemoptysis 1 TB 2 Chronic bronchitis 3 Cancer 4 Pneumonia 5 Trauma 6 Autoimmune disease

Sputum Culture cytology

Importance of culture: Detect and identify bacteria or fungi causing an infection (such as pneumonia or tuberculosis). Identify the best antibiotic to treat the infection (sensitivity testing). Monitor treatment of an infection.

Importance of Sputum Cytology: Major role: Diagnosis of malignant neoplasms involving lung both primary and metastatic. Minor role: Specific inflammatory process. Benign neoplasms.

Bacterial cells in a sample of sputum

Collection Procedure: Patient Preparation: The optimum time for specimen collection is within 15 to 30 minutes after waking and before eating breakfast. Brushing of teeth or rinsing of the mouth with water will reduce contamination by saliva. Instruct the patient to inhale and exhale deeply forcing air from the lungs using the diaphragm. Repeat until the patient coughs and is able to produce a sputum specimen.

b. Collect the specimen in the sterile container, attempting to obtain at least one teaspoon of sputum. Saliva is of no diagnostic value. Greater diagnostic yield may be obtained if specimens are submitted on three to five successive mornings.

When sufficient amounts of spontaneously produced sputum are unobtainable, specimens may be induced by inhalation of a nebulized solution composed of 15% sodium chloride, with or without 20% propylene glycol, or simply 3–8% sodium chloride heated to 115°F.

c. Add 70% alcohol as soon as possible in a volume equal to the specimen collected. Label each container with the patient name, site, source and requisition peel off number. d. STORAGE: Submit the specimen at room temperature.

The most popular techniques in handling sputum are the ‘‘pick-and-smear’’ technique and the Saccomanno methodology. I. pick-and-smear: Experience is essential to pick out significant areas for processing. They are prepared as direct smears for immediate fixation (95% ethyl alcohol or spray fixation) then stained with hematoxylin-eosin.

Saccomanno methodology: When a significant delay is anticipated between specimen taking and laboratory processing, prefixation and processing by the Saccomanno method are preferred. Cells are collected in 50% ethanol and 2% polyethylene glycol (carbowax). Upon receipt in the laboratory, a blender is used to emulsify the specimen, which is subsequently centrifuged and prepared as smears.

Curschmann`s spirals are coiled strand of mucus Curschmann`s spirals are coiled strand of mucus. On Papanicolaou stains, they appear as purple helices. They are a non-specific finding associated with chronic respiratory disorders.  

Charcot-Leyden crystals are rhomboid shaped, orangiophilic structures deriving from degenerated eosinophils in patients with severe allergic disorders such as asthma.

Charcot-Leyden crystals

Strongyloides stercoralis

Candida

Granulomatous Inflammation (Tuberculosis)

Vegetable (plant) cells

Bronchial Washings and Brushings Indications: Bronchial brushings and washings are complementary to sputum cytology in the diagnosis of pulmonary lesions. The most common indications for bronchoscopy: Persistent cough. Radiographic documentation of a new solitary pulmonary nodule. Un diagnosed hemoptysis. Persistent localized wheezes. persistent infiltrates on chest x-ray.

Bronchial washing is part of a procedure called a bronchoscopy, in which a physician looks into the lungs with a fiber optic bronchoscope to check for irregularities and take tissue samples. Technique: The physician injects saline through the bronchoscope into the lung and then suctions it back out.

By checking the wash return fluid, the doctor can diagnose bleeding, pneumonia, industrial pollutants, fungal infections and different kinds of lung cancer. Patients undergoing bronchial washing usually receive topical anesthesia with sedation. 

Bronchial brushing: is a procedure in which cells are taken from the inside of the airway mucosa or bronchial lesions. Flexible brushes are passed through the bronchoscope, and the bronchial surface is gently abraded to obtain the specimen. A bronchial brushing is used to find cancer and changes in cells that may lead to cancer. It is also used to obtain specimens for microbiologic diagnosis.

Upon withdrawing the brush, agitate the brush vigorously in a 5 to 10 mL vial of sterile saline or fixative. DO NOT APPLY THE BRUSH DIRECTLY TO SLIDES. If possible, detach the brush and leave it in the vial and better to be examined in 4 hours.