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 Table of Contents  
Year : 2019  |  Volume : 7  |  Issue : 1  |  Page : 25-32

Correlation between sputum and bronchoscopy-guided cytology (bronchoalveolar lavage fluid, transbronchial needle aspiration, and bronchial brush) with bronchial biopsy in the diagnosis of pulmonary pathology

1 Department of Pathology, TRIHMS, Naharlagun, Arunachal Pradesh, India
2 Department of Molecular Medicine and Laboratory Sciences, Army Hospital Research and Referral, Delhi, India

Date of Web Publication12-Jun-2019

Correspondence Address:
Dr. Pushpanjali R Ojha
Department of Pathology, TRIHMS, Naharlagun, Arunachal Pradesh - 791 110
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amhs.amhs_135_18

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Background: Pulmonary pathologies constitute a major ailment in terms of morbidity and mortality. Recent technological advancements provide cytological analysis that accentuates accurate diagnosis, early intervention, management, and ease of clinical follow-up with improved outcomes. This study aimed to correlate the sensitivity and describe advantages and disadvantages of the various cytological means of the diagnosis of lung pathologies along with the sequential approach. Materials and Methods: This was a prospective study performed during the period of January 2013 to January 2015. Samples of sputum and bronchoscopy-mediated bronchoalveolar lavage (BAL) fluid, air-dried and alcohol-fixed smears of bronchial brushing (BB), transbronchial needle aspiration (TBNA), and formalin-fixed bronchial biopsy tissues were received, processed, and analyzed from all clinically and radiologically suspected cases of pulmonary pathologies. Results: Two hundred cases of lung lesions were included with all the four cytological sampling interventions and tissue biopsy in the present study with an age range of 21–90 years and male:female ratio of 2.45:1. There were 111 neoplastic and 89 nonneoplastic cases. The diagnostic sensitivity was maximum with BB cytology for nonneoplastic as well as neoplastic lesions. The overall diagnostic utility observed in 200 cases reveals sputum cytology as least sensitive and BB cytology as most sensitive investigation. Conclusion: Sputum cytology is used in patients who are unfit for bronchoscopy and inpatients for their routine evaluation of underlying infection. BAL enhances yield from intraluminal lesions, and TBNA enhances yield in submucosal and mediastinal lesions. The proposed protocol for cytomorphological diagnosis should be as sputum > BAL > TBNA > BB in order of ease.

Keywords: Bronchial biopsy, bronchial brushings, bronchoalveolar lavage fluid, neoplastic pulmonary pathology, nonneoplastic, transbronchial needle aspiration

How to cite this article:
Ojha PR, Madan R, Bharadwaj R. Correlation between sputum and bronchoscopy-guided cytology (bronchoalveolar lavage fluid, transbronchial needle aspiration, and bronchial brush) with bronchial biopsy in the diagnosis of pulmonary pathology. Arch Med Health Sci 2019;7:25-32

How to cite this URL:
Ojha PR, Madan R, Bharadwaj R. Correlation between sputum and bronchoscopy-guided cytology (bronchoalveolar lavage fluid, transbronchial needle aspiration, and bronchial brush) with bronchial biopsy in the diagnosis of pulmonary pathology. Arch Med Health Sci [serial online] 2019 [cited 2023 Feb 5];7:25-32. Available from: https://www.amhsjournal.org/text.asp?2019/7/1/25/260003

  Introduction Top

The bronchopulmonary area being in direct and continuous exposure to the external environment may exhibit diverse spectrum of nonneoplastic and neoplastic pathologies. Accurate and early diagnoses of these pathologies promise to change the outcome in future. There are two effective ways for diagnosing the lung lesions – radiological and cytological. Cytological utility for diagnosis of lung pathologies had been started during the 18th century when Donne and Walshe were independently observed the presence of exfoliated respiratory cells in sputum.[1],[2] The first major study elaborating successful diagnosis of lung cancer by examination of sputum was done by Hamplen[3] in 1919 where 13 out of 25 cases show malignant cells in smears prepared from sputum.

Since last few decades, rapid advances in molecular biology, pathology, bronchology, and radiology have provided a rational basis for improving outcome. These advancements led to a better documentation of morphological changes in the bronchial epithelium before the development of clinically evident invasive lesions. The invention and implication of bronchoscope with direct visualization and sample collection from the affected area provides a new horizon to cytology. This makes availability of the intraluminal and adjacent intraparenchymal cellular elements for examination with minimal invasion.

There are five major techniques used to obtain cellular material for the diagnosis of lung pathologies: (1) sputum collection, (2) bronchoalveolar lavage fluid (BAL), (3) transbronchial needle aspiration (TBNA), (4) bronchial brushings (BBs), and (5) bronchial biopsy (BBx). BBx was obtained through transbronchial approach.

The selection of cell collection technique is based on the personal preference of the physician, patient's status, site of lesion, and other factors. The diagnostic and therapeutic efficacy of procedure varies according to the expertise, accessibility, and patient compliance. Major utility of these procedures is in the diagnosis of lung malignancies followed by infective pathology. These techniques have minimal patient discomfort and complications. The complications are usually rare and include laryngospasm, bronchospasm, hypoxia, sepsis, hemorrhage, aspiration, and cardiac arrhythmias. About 0.5% major complications and 0.8% minor complications were described in the study of Vijay et al.[4] Today, respiratory tract cytology is well established throughout the world as a vital diagnostic tool in the evaluation of lung pathology.

Among the various lung pathologies, lung cancer is the leading cause of cancer death worldwide. Unfortunately, in India, it is diagnosed when it is already in an advanced stage.

Bronchoscopy may be beneficial for visualizing central lung cancer in very early stages or in a premalignant state. The current standard of care incorporates fine-needle aspiration (FNA) cytology/core-needle biopsy for metastatic and extrathoracic lesions as well as interventional bronchoscopic techniques such as TBNA and trans-BBx for intrathoracic disease.

In the presence of obvious lung disease, the least invasive diagnostic approach should be used to make the diagnosis. Assuming that disease is isolated to the chest and a diagnosis is needed, bronchoscopy is often the first test of choice.

Based on this background, we aimed to study the various cytological modalities, correlation between their diagnostic efficacies with that of BBx (considered as gold standard), and analysis of their diagnostic values and understand the diagnostic pitfalls. Our objectives in the present study are to establish the most informative tool for diagnosis of lung pathology and to propose a cytomorphological protocol to diagnose and follow up cases with lung pathology. The study includes samples received in the department of pathology from indoor and outdoor patients collected by clinicians after procedure description and informed consent from them. We as researcher had obtained a verbal permission from the clinicians for the study; hence, ethical issues and informed consent from patients were not applicable.

  Materials and Methods Top

This was a prospective and observational study of 200 cases conducted during the period of January 2013–January 2015. Data collected and presented in terms of descriptive statistics (range, mean, sensitivity, and specificity) for quantitative variables and frequency. Percentages for category variables were presented.

Inclusion criteria

Adult cases who had some radiologically diagnosed pulmonary pathologies such as homogeneous or heterogeneous opacities, cavitary lesions, patchy areas, areas of consolidation, endobronchial or parenchymal lesions as well as suspected cases screened for lung primary malignancies and were subjected to all the cytological modalities, i.e., sputum, BAL, TBNA, BBs, and biopsy were included in the study.

Exclusion criteria

Pediatric cases and patients who had lung pathologies but could not be subjected to all the five samples and the cytological samples with normal BBx were excluded from this study.

Clinical details

All the patients were undergone complete clinical evaluation including their personal history and complete physical examination. Radiological investigations such as Chest X-Ray, HRCT thorax, chest CT scan and bronchoscopic findings were evaluated. Hematological and biochemical tests such as random blood sugar, blood urea, serum creatinine, electrolytes and immunological status regarding HIV, HCV and Hepatitis B surface antigen were done based on the clinical history of patient.


All the fresh morning expectorated sputum samples collected by the patient themselves in a sterile wide-mouth container following instruction regarding sputum production and collection were received immediately and rapidly processed by liquefaction and concentration methods under aseptic conditions. Sputum smears were examined under the microscope to look for sample adequacy and to find out the underlying pathology. Sample adequacy was defined as it must contained squamous epithelial cells, bronchial epithelial cells, and alveolar macrophages.

Bronchoscopy-guided samples

BAL, TBNA, BB, and BBx were collected under the guidance of Olympus flexible fiber-optic bronchoscope with 6.2-mm external diameter and 5.6-mm internal diameter in a sterile container under aseptic condition. Instruments required were forceps for biopsy, BBs for taking brushings, normal saline for washings and sample collection, 10% formalin for preservation of biopsy sample, Whatman filter paper to orient the BBx tissue, and wide-mouth sterile containers.

Bronchoalveolar lavage fluid

Bronchoscope was negotiated to the lower bronchial tree, BAL fluid was collected after infusing about 5–10-ml normal saline, and the resulting material was aspirated by means of suction apparatus, collected in sterile container, and sent to the laboratory immediately where it was centrifuged, and the sediment was poured in to a clean  Petri dish More Details, keeping it against a black background. Any solid particle or bloody material was picked and smeared onto the slide, in such a way, that the smear was only slightly thicker than the blood smear and even. These smears were then fixed and stained.

Bronchial brushing

BB was obtained during bronchoscopy after complete visualization of tracheobronchial tree. BC-202D-2010 (Olympus) BB of 1150-mm length, 2.0-mm minimal channel diameter, and 10-mm brush length mounted on a steel guidewire was introduced through the inner channel of the bronchoscope to brush the areas which were considered abnormal under bronchoscopy. Sample was spread on 75 mm × 25 mm clean glass slides, air-dried and alcohol-fixed, and sent to the laboratory where they were stained.

Transbronchial needle aspiration

TBNA was done with EB2519-A15 (Endo-Flex). Needle with 15-mm length and 1.8-mm diameter was introduced under the bronchoscopic guidance transbronchially into the underlying mass and aspirated slowly. The aspirate thus collected was spread on glass slides and sent to laboratory where they were stained [Figure 1].
Figure 1: Age and sex distribution of nonneoplastic and neoplastic pulmonary pathologies

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Bronchial biopsy

The sample taken out through the rat tooth fenestrated with alligator jaw forceps with working length 1050 mm and minimum channel size of 2.0 mm was fixed on Whatman filter paper with mucosal surface orienting upward, kept in 10% formalin-filled container, and sent to the laboratory. The BBx tissues were received as multiple well-mounted and oriented small bits in 10% formalin solution. Tissues were fixed overnight, processed on next day and embedded in paraffin. Thin sections cut with the help of microtome and fixed on clean glass slides.

Smears from sputum, BAL, and TBNA were stained with Leishman–Giemsa (LG) stain, Papanicolaou (Pap) stain, and Ziehl–Neelsen (ZN) stain for acid-fast bacilli, Gram stain for bacteria, PAS and Grocott stain for fungal elements, and India ink for yeasts and capsulated organisms. The samples were also sent for bacterial and fungal cultures and sensitivity to microbiology department.

The BBx tissues were stained with hematoxylin and eosin, Pap, ZN, PAS, and Grocott stains. Immunohistochemical stains such as EMA, p40, and p63 for squamous cell carcinoma (SCC), CK7, TTF-1, and napsin A for adenocarcinoma, CD20 for lymphoma, and synaptophysin and chromogranin for small cell carcinoma were also applied. Cytological specimens were analyzed for sample adequacy, documentation of findings in epithelial cells, presence of any infection or malignancy, and any deviation from usual cytology.

Histology slides were studied for representation of adequate biopsy, morphological findings in lining and glandular epithelium, and stromal findings including inflammatory/granulomatous pathology.

  Results Top

Out of 200 cases studied, adults of 21–90 years' age range with maximum cases fall in 61–80 years, age group were found. Sex distribution shows 142 males and 58 females with a male: female ratio of 2.45:1.

Among 200 cases of lung lesions, 111 were neoplastic and 89 nonneoplastic. The neoplastic lesions were divided into three categories as SCC, adenocarcinoma, and others. Out of 111, SCC constitutes 54 cases, adenocarcinoma constitutes 33 cases, and others constitute 24 cases. In the nonneoplastic category, 34 cases were of nonspecific inflammation, 20 of tuberculosis, 17 of acute inflammatory lesions, 14 of fungal infection, 2 of sarcoidosis, and 2 of parasitic infections.

Result of endobronchial biopsy was taken as gold standard, and all the data were analyzed in comparison to endobronchial biopsy results. Sensitivity of various samples in the diagnosis of SCC was found as 3.70%, 24.07%, 35.19%, and 88.88% for sputum, BAL fluid, TBNA, and BB, respectively. In case of adenocarcinoma, diagnostic sensitivity was found as 3.03%, 39.39%, 48.48%, and 60.60% with sputum, BAL fluid, TBNA, and BB cytology, respectively. Tumors included in the group of others were small cell carcinoma, bronchioloalveolar carcinoma, lymphoma, and metastatic lung carcinoma. Out of 24 such cases, diagnostic sensitivity of sputum, BAL, TBNA, and BB was 4.16%, 12.50%, 16.66%, and 87.50%, respectively [Table 1].
Table 1: Sensitivity of tests in neoplastic lesion

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Among nonneoplastic lesions, diagnostic sensitivity of sputum, BAL, TBNA, and BB cytology for cases of acute inflammatory lesion was 5.88%, 29.41%, 58.82%, and 94.12%, respectively. For cases of tuberculosis, the sensitivity of sputum, BAL, TBNA, and BB cytology was 15.00%, 90.00%, 65.00%, and 95.00%, respectively. Fungal infections included in the study were aspergillosis, mucormycosis, candidiasis, pneumocystis, and histoplasmosis. Out of 14 cases diagnosed histologically, the diagnostic sensitivity of sputum, BAL, TBNA, and BB cytology was 7.14%, 57.14%, 71.43%, and 92.86%, respectively. Paragonimus was identified with 50.00% sensitivity by sputum, BAL, and BB cytology. Sarcoidosis cases were also observed with 50.00% sensitivity by BAL and TBNA and 100.00% sensitivity with BB. Sputum cytology was negative in cases of sarcoidosis. Out of 34 cases of nonspecific inflammation, sensitivity of sputum, BAL, TBNA, and BB cytology was 5.88%, 47.06%, 58.82%, and 97.06%, respectively. The overall diagnostic utility of sputum, BAL, TBNA, and BB cytology in terms of sensitivity in 200 cases was found to be 6.00%, 39.00%, 46.50%, and 86.50%, respectively [Table 2] and [Table 3].
Table 2: Sensitivity of tests in nonneoplastic lesions

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Table 3: Overall test sensitivity

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  Discussion Top

Diagnostic evaluation of pulmonary pathology starts with cytological examination of sputum which was first described by Leeuwenhoeck AV in 1674 when he observed squamous cells, lymphocytes, and macrophages in his preparations.[5] Donne published the first work on exfoliated cells of respiratory tracts in the year 1845.[1],[2] Walshe in 1846 showed the presence of tumor cells in sputum.[2] Hamplen in 1887 validated the cytodiagnosis by publishing a case report in which tumor cells recognized from sputum sample from a patient 5 months before the death and bronchogenic cancer were confirmed at autopsy.[3] Dudgeon and Wrigley in 1935 published a paper on wet-film fixation of sputum smears in a mixture of ethyl alcohol, mercuric chloride, and acetic acid for identification of malignant cells.[6] Johnston compared the FNA biopsy versus sputum and bronchial material in the diagnosis of lung cancer and concluded that the techniques of conventional respiratory cytology and FNA biopsy cytology are complementary in the diagnosis of lung cancer.[7] While the percentage of lung cancers diagnosed by FNA biopsy cytology alone is much greater than that obtained by conventional respiratory cytology, more than one-fourth of these cancers could be detected by the less invasive techniques of sputum collection and bronchoscopy.

Sputum is a most easily producible, noninvasive, and cost-effective sample for cytological analysis but with the highest rate of sample inadequacy and diagnostic inefficacy. Most of the samples collected are saliva only, without bronchial epithelial cells and alveolar macrophages, which were excluded from the study. The sensitivity of the present study is 6.00%, which is much low as compared with previously done studies of Dahlgren and Lind (64%) and Chopra et al. (18%).[8],[9],[10] Sputum cytology revealed 3.60% sensitivity for neoplastic and 8.99% sensitivity for nonneoplastic lesions. Jamal A et al. in their study stressed on adequate sampling, a major pitfall in sputum diagnosis which was the most important factor in the present study also.[11] The other factors for inadequacy were poor expectorating technique, peripherally located lesions and submucosal lesions and noncohesive and nonproductive pulmonary lesions.

In 1972, Dahlgren and Lind did a comparative study from transthoracic needle biopsy and sputum cytology and concluded that 93% were diagnosed by aspiration biopsy and 64% by sputum cytology[8],[10] [Figure 2].
Figure 2: (a) Sputum sample in wide-mouth sterile container. (b) Flexible fiber-optic bronchoscope (Olympus). (c) Bronchial biopsy forceps. (d) Transbronchial aspiration needle. (e) Bronchial brush

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After the invention of bronchoscope by Gustav Killian (The Father of Bronchoscopy) in 1897 and advancement with flexible one, there was new era began in the cytodiagnosis of lung pathology which was least invasive, with better patient compliance, direct visualization, and sample collection from exact site with good cellular yield. Flexible bronchoscopes were more suitable for procedure as the entire structure of bronchial tree shows pulsatile and respiratory movements.

BAL, TBNA, and BBs collected from the respiratory tract yielded a significant amount of cytological material with which the emphasis shifted from diagnosis of malignancy in operable patients and confirmation of metastases, to the use of cytology as a first-line diagnostic procedure on which crucial management decisions could be based.

In BAL technique, the sample adequacy depends on several factors, especially the degree of differentiation of malignant growth, preservation of the morphology of cytological material obtained, and technical skill of the pulmonologist who is retrieving the lavage fluid from the bronchus.

Chopra et al. in 1974 did fiber-optic bronchoscopy (washing, brushings, and biopsies) along with pre- and postbronchoscopic sputum collection in 70 histologically proved lung cancer patients.[9] Of all the various samples, brushings gave the highest yield of 67% followed by BBx of 66%. Prebronchoscopic sputum sample had the lowest yield of 18%.

The yield from combining bronchial washings and brushings was greater than from either procedure alone, but combination with transbronchial biopsy did not result in any significant improvement. Solomon et al. were observed 90% success rate in lung cancer diagnosis with bronchial brushings in comparison to 20% success rate with bronchial washings in their study.[12] Gupta in his study concluded that the combination of BBs and washings increases the sensitivity of either method alone.[13]

In 1993, Flint studied bronchial washings from 111 patients with clinical and radiological evidence of lung mass.[14] He also prepared cell blocks from washings that increased the yield by 9% but were not cost-effective. Sing et al. in their study of pulmonary cytological diagnosis of lung cancer found that sensitivity of BB cytology was 50%, but when combined with sputum, cytology sensitivity improved to 64%.[15] They also said that the diagnostic yield depends on the location, histological typing of tumor, and stage. Brushing cytology detected more advanced and centrally located malignancies. In 1997, Sing et al. also compared the diagnostic accuracy between BBs and sputum cytology and found brushing being superior for the centrally located lesions.[15]

Sensitivity of BAL cytology in the present study is 39.00%, which is similar to those of the study of Gaur et al. with 39.4% and Rangdaeng et al. with 36% sensitivity.[16],[17] This study has lower yield than Truong et al. and Ng and Horak et al. which ranges from 66.0% to 74%.[18],[19]

BAL cytology is the study of exfoliated cells inside the lumen of bronchial tree which shows increased yield in terms of sensitivity, specificity, and accuracy with subsequent sampling as documented by Bhagat et al.[20] The amount of normal saline used for lavage may affect the yield.[20] The other factors affecting the yield are as follows: location of lesion, size of lesion, technical skill of bronchoscopist, degree of dis-cohesiveness of the lesion, and postbronchoscopic washings because of traumatic exfoliation. Sensitivity of the test in diagnosing Mycobacterium tuberculosis is 90.00% but less in other infectious lesions. Sensitivity of BAL in diagnosing malignancies is 24.07% for SCC and 39.39% for adenocarcinoma in comparison to 17.9% for SCC and 3.6% for adenocarcinoma in the study of Ng and Horak et al.[19] The overall sensitivity of 88.57% was calculated for both centrally and peripherally located lung tumors in the study of Khilanath and Prasad.[21]

Diagnostic accuracy of BAL for various types of malignancies was as follows – 71.4% for poorly differentiated carcinoma, 17.9% for SCC, 7.1% for small cell carcinoma, and 3.6% for adenocarcinoma. Rangdaeng et al. stated that overall sensitivity of sputum, bronchial washing, and BAL was 0.22, 0.45, and 0.36, respectively.[17] Diagnostic accuracy for endobronchial lesions in the study of Puchalski was 68%[22] and for endoscopically visible malignancy was 39% in the study of Dobler and Crawford.[23]

BB technique has the advantage that the surface of the suspicious lesion is scraped by the help of a brush to dislodge the cells of those well-differentiated malignant lesions too, which do not exfoliate cells readily and show better preserved morphological details in comparison to the cells which have already exfoliated into the bronchial cavity. Gaur et al. stated that the values of sensitivity, specificity, and overall accuracy of BB were 87.3%, 97.6%, and 93.9%, respectively,[16] which were much superior to BAL. They concluded that BB is a much superior technique in the diagnosis and morphological typing of lung cancers, as it demonstrates far better specificity, sensitivity, and accuracy, in comparison to BAL. Dobler and Crawford stated that diagnostic yield of BB was 51% in lung cancer.[20] They concluded that bronchial washing and brushing significantly increase the yield of bronchoscopy with endoscopically visible lesions. According to Puchalski, diagnostic accuracy of BBs for central lesions was 72%.[19] Rangdaeng S et al. stated that BB provided a significantly far superior sensitivity (0.800) than those of three former methods with P < 0.05 by Fisher's exact test.[16]

The sensitivity of BB cytology in this study is 86.50% in comparison to Chopra (67.00%),[9] Sing (50.00%),[15] Gaur (87.30%),[16] and Mufti and Mokhtar (82%).[24] There were cases reported as bronchogenic carcinoma on radiology but showed tubercular granulomas on cytology and were confirmed on biopsy. The yield is higher with this study because of technical skill of bronchoscopist and direct visualization of the lesion. These studies also reveal that the combination of forceps biopsy and BB cytology gave best results for cancer in 57 cases (90.5%). Piaton et al. stated that biopsy is the cornerstone of diagnosis; however, the cytological materials may provide critical information on accurate typing of small cell and non-small cell carcinoma of the lung which is crucial in therapeutic and prognostic implication.[25] The present study has 86.50% positivity in comparison to 46.5% positivity of TBNA and 39.00% with BAL. This implicates the highest yield on BB. The advantages of the BB cytology are simple, rapid, and easy to perform with least complications as compared to biopsy. All lesions neither should be amenable to biopsy nor some patients should be fit due to compromised lung function. Combination of biopsy and BB is ideal for definitive diagnosis, but BB also gives equally good results as a biopsy.

TBNA is a relatively sensitive, accurate, and safe technique useful in the diagnosis of submucosal lesions, peripheral nodules, externally present masses compressing the lumen, and pretracheal, paratracheal, perihilar and mediastinal lymph nodes. Sharafkhaneh et al. in their article concluded that despite high yield for diagnostic material, there is underutilization of the technique.[26] Dong Z et al. in their study found the sensitivity and specificity of 94.52% and 95.12%, respectively. The sensitivity of SCC, adenocarcinoma, and small cell carcinoma was up to 88.24%, 100.00%, and 96.00%, respectively. The specificity of SCC, adenocarcinoma, and small cell carcinoma reached to 100.00%, 100.00%, and 99.25%, respectively.[27] According to Khoo et al., targeting the mediastinum first with endoscopic needle biopsy in patients with lymphadenopathy and suspected lung cancer enables diagnosis and staging to be achieved conclusively with a single procedure[28] [Figure 3] and [Figure 4].
Figure 3: (a) Bronchial brush with Leishman–Giemsa stain under ×20 – Smear shows well-formed epithelioid granuloma. (b) Sputum with Ziehl–Neelsen stain under ×100 – Smear shows numerous cylindrical, round-edged, beaded, acid-fast bacilli. (c) Bronchial brush with Leishman–Giemsa stain under ×20 – Smear shows candida with budding yeast form. (d) Bronchoalveolar lavage fluid with Grocott stain under ×100 – Smear shows cup and saucer appearance of Pneumocystis jirovecii

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Figure 4: (a) Contrast-enhanced computed tomography chest – heterogeneously enhancing mass lesion in the right upper lobe of lung (RUL). (b) Bronchial brush Leishman–Giemsa stain (×40) – Abortive glands of malignant cells suggestive of adenocarcinoma. (c) Contrast-enhanced computed tomography chest – Heterogeneously enhancing mass lesion in anterior segment of left upper lobe of lung (LUL) with necrosis. (d) Bronchial brush Leishman–Giemsa stain (×40) – Polygonal malignant squamous cells in single cluster with intercellular bridges suggestive of squamous cell carcinoma. (e) Transbronchial needle aspiration Leishman–Giemsa stain (×10) – Clusters of malignant spindle cells suggestive of spindle cell tumor. (f) Bronchoalveolar lavage fluid Leishman–Giemsa stain (×20) – Monotonous sheets of malignant lymphocytes suggestive of lymphoma

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Ye et al. in their study stationed the mediastinal lymph nodes according to the puncture site as the upper paratracheal (2R, 2 L), subcarinal (7), the lower paratracheal and hilar (4R, 4 L, 10R, and 10 L), the right paraesophageal (8R), and the interlobar station (11 L, 11R).[29] The sensitivity was 95.08% with predominance of cases involving 4R in comparison to the present study (46.50%).[29] The postprocedural complications are least with TBNA and include hemorrhage and mild pain only. The yield of the test depends on location of lesion and technical skill of the bronchoscopist. Peripherally located lesions may be negative on TBNA cytology but can be identified by transthoracic needle aspiration. Yield may be increased by proper visualization of the lesion and then taking the samples from submucosal lesions and lesions compressing the bronchial tree.

BBx may be preoperative, either in the form of trucut or punch biopsy in which a small tissue bit was obtained to provide diagnosis and characterization of lesion and postoperative in the form of excision biopsy to know the diagnosis, extent of invasion, and nature of lesion. Puchalski in their study found that BBx classified 36.6% cases as poorly differentiated carcinoma, 29.6% cases as SCC, and 19.7% cases as small cell carcinoma.[22] The similar result was obtained in the present study also.

  Conclusion Top

The aims and objectives of this study are met by assessing the diagnostic utility of sputum, BAL, TBNA, and BB cytology in the diagnosis of nonneoplastic and neoplastic pulmonary lesions.

Sputum cytology is the noninvasive, cost-effective, and easiest diagnostic technique but least informative hence cannot be used for diagnostic utility but is indicated in patients who are unfit for bronchoscopy and inpatients for their routine evaluation of underlying infection.

BAL has a better yield than sputum cytology but less than that of TBNA and BB. The yield increases with repeated sampling and postbronchoscopic sample collection. Intraluminal lesions are positive on BAL, but submucosal and peripheral lesions give negative results.

TBNA is indicated with increased diagnostic yield in submucosal and mediastinal lesions.

BB is the diagnostic modality of choice in cytology for the diagnosis of lung pathologies whose sensitivity is next to the endobronchial biopsy. It is the least invasive, cost-effective diagnostic technique which provides earlier and accurate diagnosis, thus facilitating the early diagnosis and treatment of a patient. It also has prognostic values. In future, BB can be very useful in early detection of lung cancer.

The proposed protocol for cytomorphological diagnosis will include all four modalities, beginning with sputum > BAL > TBNA > BB in order of ease and should be performed sequentially for all cases. Gold standard, however, is by biopsy.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]

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