Case report: Dramatic response to pralsetinib in an elderly patient with advanced RET-fusion positive papillary thyroid carcinoma.

We are recently faced with a progressive evolution of the therapeutic paradigm for radioiodine refractory differentiated thyroid cancer (RAI-R DTC), since the advent of tissue agnostic inhibitors. Thus, tumor genotype assessment is always more relevant and is playing a crucial role into clinical practice. We report the case of an elderly patient with advanced papillary thyroid carcinoma (PTC) harboring RET-CCDC6 fusion with four co-occurring mutations involving PI3KCA, TP53, and hTERT mutations, treated with pralsetinib under a compassionate use program. Despite the high histological grade and the coexistence of aggressive RET co-mutations, an impressive metabolic and structural tumor response has been obtained, together with a patient's prolonged clinical benefit. A timely comprehensive molecular testing of those cases wild-type for the common thyroid carcinoma BRAF V600E-like and RAS-like driver mutations may uncover actionable gene rearrangements that can be targeted by highly selective inhibitors with great potential benefit for the patients.

Diagnosis and Molecular Profiling of Lung Cancer by Percutaneous Ultrasound-Guided Biopsy of Superficial Metastatic Sites Is Safe and Highly Effective.

BACKGROUND: Diagnosis, staging, and molecular profiling of lung cancer are mostly carried out with bronchoscopy or CT-guided aspiration/biopsy. However, patients with locally advanced or advanced disease often harbor "superficial" metastases for which a percutaneous, ultrasound-assisted needle aspiration/biopsy (US-NAB) might represent an equally effective yet less invasive and costly alternative. PATIENTS AND METHODS: We reviewed a prospectively collected database of consecutive patients with known/suspected lung cancer who underwent a US-NAB of a suspected "superficial" metastasis. Cancer genotyping was carried out with next-generation sequencing using the Oncomine™ Focus DNA and RNA fusion panels. PD-L1 immunohistochemistry was performed with the SP263 antibody. Feasibility, diagnostic yield for tissue diagnosis, sensitivity for malignancy, diagnostic yield for the molecular profiling, and complications were the study endpoints. RESULTS: A total of 98 lesions were evaluated, and 93 were biopsied (95% feasibility). The spectrum of sampled sites included lymph nodes (63 patients), bone (11), subcutaneous tissue (8), muscle (7), and the pleura (4). The diagnostic yield for a tissue diagnosis was 93% (91/98). US-NAB correctly identified 85 of the 87 patients finally diagnosed with malignancy (98% sensitivity). Cancer genotyping and PDL1 testing were successfully completed in 41/42 patients (98%) and in 40/50 patients (80%) for whom these tests were requested, respectively. No complications were observed. CONCLUSION: US-NAB of "superficial" metastasis of lung cancer is safe and is associated with high success for diagnosis and molecular profiling. In this clinical setting, using US-NAB as a first-step technique would significantly limit the use of more invasive and costly diagnostic procedures.

Reliability of programmed death ligand 1 (PD-L1) tumor proportion score (TPS) on cytological smears in advanced non-small cell lung cancer: a prospective validation study.

INTRODUCTION: Programmed death-ligand 1 (PD-L1) immunohistochemistry (IHC) assessment is mandatory for the single agent pembrolizumab treatment of patients with advanced non-small cell lung cancer (NSCLC). PD-L1 testing has been validated and is currently certified only on formalin-fixed paraffin-embedded materials but not on cytological smears. Unfortunately, a significant proportion of patients, having only cytological material available, cannot be tested for PD-L1 and treated with pembrolizumab. In this study, we aimed to validate PD-L1 IHC on cytological smears prospectively by comparing clone SP263 staining in 150 paired histological samples and cytological smears of NSCLC patients. METHODS: We prospectively enrolled 150 consecutive advanced NSCLC patients. The clone SP263 was selected as, in a previous study of our group, it showed higher accuracy compared with clones 28-8 and 22-C3, with good cyto-histological agreement using a cut-off of 50%. For cyto-histological concordance, we calculated the kappa coefficient using two different cut-offs according to the percentage of PD-L1 positive neoplastic cells (<1%, 1-49% and ⩾50%; <50%, ⩾50%). RESULTS: The overall agreement between histological samples and cytological smears was moderate (kappa = 0.537). However, when the cyto-histological concordance was calculated using the cut-off of 50%, the agreement was good (kappa = 0.740). With the same cut-off, and assuming as gold-standard the results on formalin-fixed paraffin-embedded materials, PD-L1 evaluation on smears showed specificity and negative predictive values of 98.1% and 93.9%, respectively. CONCLUSION: Cytological smears can be used in routine clinical practice for PD-L1 assessment with a cut-off of 50%, expanding the potential pool of NSCLC patients as candidates for first-line single agent pembrolizumab therapy.

Pulmonary adenocarcinoma with psammoma bodies is associated with a specific endobronchial ultrasound pattern and a high prevalence of actionable driver mutations.

INTRODUCTION: Pulmonary adenocarcinoma with psammoma bodies (PAPBs) is a rare histological variant whose association with a high prevalence of targetable mutations has been suggested by scant literature reports describing small series. We aim to describe the endobronchial ultrasound (EBUS) pattern and the molecular profile by next-generation sequencing of an Italian series of patients with PAPBs. MATERIAL AND METHODS: Over a 8-year period (2012-2019), we identified 15 patients with a very uncommon endobronchial ultrasound (EBUS) heterogeneity pattern characterized by the presence of multiple to countless, punctate non-shadowing foci ("starry sky" sign) which were not evident at CT and corresponded to psammoma bodies at pathological examination. The clinical, radiological, pathological and molecular findings of these patients were retrieved and analyzed. RESULTS: Pathological examination of the EBUS-TBNA specimens revealed malignancy (12 pulmonary adenocarcinoma, 2 breast carcinoma, 1 colonic carcinoma) and showed the presence of psammoma bodies in all of the 15 patients with the starry sky sign. Among the 12 patients with pulmonary adenocarcinoma with psammoma bodies, female sex (8/12, 66.7 %) and never-smoking habit (6/12, 50 %) were prevalent. Molecular tumor profiling using the Oncomine™ Focus DNA and RNA fusion panels was successfully performed in 11/12 patients and revealed 10 genetic alterations (BRAF mutation, 4; EGFR mutation, 2; ALK rearrangement, RET rearrangement, PIK3CA mutation, CDK4 amplification 1) in 7 patients (63.6 %). CONCLUSION: The present series suggests that pulmonary adenocarcinoma with psammoma bodies is associated with a readily identifiable EBUS pattern and with a high prevalence of different, often uncommon and actionable, driver mutations.

Interobserver agreement between pathologist, pulmonologist and molecular pathologist to estimate the tumour burden in rapid on-site evaluation smears from endosonography and guided bronchoscopy.

OBJECTIVE: A growing number of studies have suggested that non-pathologists can reliably assess the adequacy and malignancy in rapid on-site evaluation (ROSE) smears prepared during endoscopic sampling procedures. However, no study has verified whether they can also consistently estimate the tumour burden, which is critical for the molecular profiling of lung cancer. We aimed to assess the interobserver agreement (IOA) between a pathologist, a pulmonologist (previously trained in lung and lymph node cytopathology) and a molecular pathologist for the tumour burden in ROSE smears. METHODS: The ROSE smears of consecutive patients with suspected lung cancer undergoing endosonography or guided bronchoscopy were assessed independently by a pathologist, a pulmonologist and a molecular pathologist (gold standard). The IOA for the tumour burden, assessed through k-statistics, was the primary outcome. RESULTS: A total of 322 ROSE smears obtained from 162 patients were evaluated. The IOA between the molecular pathologist and pulmonologist was very good (moderate to substantial), although slightly inferior to the IOA between the molecular pathologist and pathologist in the whole slide set (k: 0.707, 95% confidence interval [CI]: 0.677-0.739 vs 0.793, 95% CI: 0.762-0.815), as well as in smears prepared from lymphadenopathy (k: 0.783, 95% CI: 0.760-0.855 vs 0.827, 95% CI: 0.728-0.892) or from pulmonary nodules/masses (k: 0.558, 95% CI: 0.416-0.686 vs 0.715, 95% CI: 0.621-0.767). CONCLUSIONS: A professionally trained pulmonologist can reliably estimate the tumour burden in bronchoscopically derived ROSE smears, especially in the setting of lymphadenopathy. This can be particularly useful in institutions where a cytopathologist is not available regularly.

Adequacy of endosonography-derived samples from peribronchial or periesophageal intrapulmonary lesions for the molecular profiling of lung cancer.

INTRODUCTION AND OBJECTIVES: Endosonography is increasingly used for the diagnosis of centrally located, bronchoscopically invisible intrapulmonary lesions, but data regarding its utility for molecular profiling are lacking. We aimed to assess the suitability of endosonography samples obtained from intrapulmonary lesions for cancer genotyping and programmed-death ligand 1 (PD-L1) testing. METHODS: A prospectively collected database regarding 99 consecutive patients undergoing endosonography for the diagnosis of an intrapulmonary lesion was retrospectively reviewed. Genotyping ± PD-L1 testing was carried out in the 53 patients with advanced lung cancer and was classified as complete if all clinically indicated tests could be performed, incomplete if at least one test could not be carried out, and unsuccessful if the sample was unsuitable for molecular analysis. RESULTS: All clinically indicated biomarkers could be tested in 44 (83%) patients, whereas the molecular profiling was classified as incomplete in 6 (11.3%), and unsuccessful in 3 (5.7%). Thirty-seven genetic alterations (KRAS mutation, 17; EGFR mutation, 17; ALK rearrangement, 3) and 2 cases of PD-L1 expression >50% were found in 31 (58%) patients. EGFR was successfully analysed in 94.1% of cases, KRAS in 93.9%, ALK in 89%, ROS1 in 90% and PD-L1 in 63.1%. CONCLUSION: Endosonography-derived samples from intrapulmonary lesions were suitable for a thorough molecular profiling in most patients. The few cases of incomplete accomplishment of the testing algorithm were related to the failure of PD-L1 analysis due to the exhaustion of the sample or the lack of sufficient tumour cells in the paraffin-embedded material.

"Melting Lymph Node Sign": The Endobronchial Ultrasound Pattern Of Cystic Mediastinal Nodal Metastases.

Cystic change in metastatic lymph nodes occurs in certain types of tumors (ie, papillary thyroid carcinoma and squamous cell carcinoma of the Waldeyer's ring) and it is usually observed in the head and neck region. We report on a series of 6 patients with mediastinal metastasis from lung cancer in whom the endobronchial ultrasound showed that most of the lymph node tissue had "melted," leading to the formation of a single, anechoic, avascular cavity. Besides the unique endobronchial ultrasound pattern, we describe the imaging and pathology findings of this unusual presentation of malignant mediastinal lymphadenopathy to facilitate its recognition.

A Trained Pulmonologist Can Reliably Assess Endosonography-Derived Lymph Node Samples during Rapid On-Site Evaluation.

BACKGROUND: The widespread use of rapid on-site evaluation is hampered by constraints related to time and resources, inadequate reimbursement, and evidence from randomized trials that show a lack of increase in diagnostic yield and specimen adequacy associated with its usage. OBJECTIVE: We aimed to verify whether a pulmonologist can assess endosonography-derived lymph node samples after a comprehensive and reproducible training provided by a specialist pathologist. METHODS: Prospective, observational trial structured in three phases. In the first (training) phase, a pathologist critically evaluated the smears from 150 archival endosonography cases with a pulmonologist. In the second (test) phase, the pulmonologist was asked to assess 50 archival endosonography-derived samples. In the last (real-life) phase, the pulmonologist classified the samples from 200 patients during the endosonography. The overall agreement between pulmonologist and pathologist (gold standard), assessed through κ-statistics, was the primary outcome. The agreement for the identification of specific cytological categories was the secondary outcome. RESULTS: The overallagreement between pulmonologist and pathologist was 84% (κ0.765, 95% CI 0.732-0.826) in the test phase and 89.7% (κ 0.844, 95% CI 0.799-0.881) in the real-life phase. The agreement for specific cytological categories was 92.7% (95% CI 0.824-0.980) for inadequate samples, 90.3% (95% CI 84.5-94.5%) for reactive lymphadenopathies, 90.5% (95% CI 0.845-0.946) for malignancy, and 73% (95% CI 0.515-0.897) for granulomatous samples. CONCLUSIONS: A trained pulmonologist can reliably assess adequacy and malignancy for endosonography-derived samples, which could be useful in institutions where a cytopathologist/cytotechnician is not available regularly.

An uncommon cause of hemoptysis: aortobronchial fistula.

BACKGROUND: Hemoptysis is a frequent sign of respiratory and non-respiratory diseases. While in most cases the underlying cause is rapidly identified, sometimes the real etiology might be misdiagnosed with dramatic delay in treatment. CASE PRESENTATION: A 46-year-old man with hiatal hernia and a history of aortic surgery for aortic coarctation presented with dramatic episodes of hemoptysis and subsequent severe anemia (6,9 g/dl). Digestive and respiratory endoscopy resulted not exhaustive, thus he underwent a contrast-enhanced computed tomography (CT) scan of the chest that showed an aneurysmal dilatation of the descending thoracic aorta with suspected aortobronchial fistula. He underwent cardiac surgery that confirmed the diagnosis and successfully treated the fistula. CONCLUSION: We briefly review the literature to raise clinical awareness on this uncommon cause of hemoptysis.

Endobronchial ultrasound-guided transbronchial needle aspiration with the flexible 19-gauge needle.

INTRODUCTION AND OBJECTIVES: Endosonography has become standard of care in the diagnostic work-up of mediastinal lymphadenopathy and peribronchial lung lesions, but its success rate in some specific settings/conditions may be hampered by limited needle flexibility and size. We report on our initial experience with the 19G Flex needle, characterized by larger size and greater flexibility as compared with the currently available cytology needles. METHODS: Retrospective review of prospectively collected data on the first 13 consecutive patients submitted to endosonography with the 19G Flex needle. Patients were included if they had: (a) suspicion of a histologically complex disease (ie, lymphoma); (b) suspicion of an advanced lung cancer possibly requiring extensive genotyping; (c) a lesion whose sampling with a 22G needle had failed because of lack of visibility when the needle was loaded into the scope. RESULTS: The 13 patients enrolled had a mean age of 58.15 ± 17 years and a male to female ratio of 8:5. Target lesions (mean size 18.6 ± 6.4 mm) were lymphadenopathies (9 patients), lung lesions (3 patients) and a pleural nodule (1 patient). Histology core/s and a definite diagnosis (adenocarcinoma, 4 cases; lymphoma, 2; mesothelioma, 2, metastases from extrathoracic tumors, 2; non-small-cell lung cancer not otherwise specifiable, 1; small cell carcinoma, 1; sarcoidosis, 1) were obtained in 100% of patients. A single case of self-resolving bleeding was the only complication we observed. CONCLUSIONS: Preliminary results obtained with the dedicated Flex 19G needle are promising, as sample size/quality is satisfactory and the needle influence on scope flexibility is minimal.