The current state of digital cytology and artificial intelligence (AI): global survey results from the American Society of Cytopathology Digital Cytology Task Force.

INTRODUCTION: The integration of whole slide imaging (WSI) and artificial intelligence (AI) with digital cytology has been growing gradually. Therefore, there is a need to evaluate the current state of digital cytology. This study aimed to determine the current landscape of digital cytology via a survey conducted as part of the American Society of Cytopathology (ASC) Digital Cytology White Paper Task Force. MATERIALS AND METHODS: A survey with 43 questions pertaining to the current practices and experiences of WSI and AI in both surgical pathology and cytology was created. The survey was sent to members of the ASC, the International Academy of Cytology (IAC), and the Papanicolaou Society of Cytopathology (PSC). Responses were recorded and analyzed. RESULTS: In total, 327 individuals participated in the survey, spanning a diverse array of practice settings, roles, and experiences around the globe. The majority of responses indicated there was routine scanning of surgical pathology slides (n = 134; 61%) with fewer respondents scanning cytology slides (n = 150; 46%). The primary challenge for surgical WSI is the need for faster scanning and cost minimization, whereas image quality is the top issue for cytology WSI. AI tools are not widely utilized, with only 16% of participants using AI for surgical pathology samples and 13% for cytology practice. CONCLUSIONS: Utilization of digital pathology is limited in cytology laboratories as compared to surgical pathology. However, as more laboratories are willing to implement digital cytology in the near future, the establishment of practical clinical guidelines is needed.

Digital cytology part 1: digital cytology implementation for practice: a concept paper with review and recommendations from the American Society of Cytopathology Digital Cytology Task Force.

Digital cytology and artificial intelligence (AI) are gaining greater adoption in the cytopathology laboratory. However, peer-reviewed real-world data and literature are lacking regarding the current clinical landscape. The American Society of Cytopathology in conjunction with the International Academy of Cytology and the Digital Pathology Association established a special task force comprising 20 members with expertise and/or interest in digital cytology. The aim of the group was to investigate the feasibility of incorporating digital cytology, specifically cytology whole slide scanning and AI applications, into the workflow of the laboratory. In turn, the impact on cytopathologists, cytologists (cytotechnologists), and cytology departments were also assessed. The task force reviewed existing literature on digital cytology, conducted a worldwide survey, and held a virtual roundtable discussion on digital cytology and AI with multiple industry corporate representatives. This white paper, presented in 2 parts, summarizes the current state of digital cytology and AI practice in global cytology practice. Part 1 of the white paper presented herein is a review and offers best practice recommendations for incorporating digital cytology into practice. Part 2 of the white paper provides a comprehensive review of AI in cytology practice along with best practice recommendations and legal considerations. Additionally, the results of a global survey regarding digital cytology are highlighted.

Digital cytology part 2: artificial intelligence in cytology: a concept paper with review and recommendations from the American Society of Cytopathology Digital Cytology Task Force.

Digital cytology and artificial intelligence (AI) are gaining greater adoption in the cytology laboratory. However, peer-reviewed real-world data and literature are lacking in regard to the current clinical landscape. The American Society of Cytopathology in conjunction with the International Academy of Cytology and the Digital Pathology Association established a special task force comprising 20 members with expertise and/or interest in digital cytology. The aim of the group was to investigate the feasibility of incorporating digital cytology, specifically cytology whole slide scanning and AI applications, into the workflow of the laboratory. In turn, the impact on cytopathologists, cytologists (cytotechnologists), and cytology departments were also assessed. The task force reviewed existing literature on digital cytology, conducted a worldwide survey, and held a virtual roundtable discussion on digital cytology and AI with multiple industry corporate representatives. This white paper, presented in 2 parts, summarizes the current state of digital cytology and AI practice in global cytology practice. Part 1 of the white paper is presented as a separate paper which details a review and best practice recommendations for incorporating digital cytology into practice. Part 2 of the white paper presented here provides a comprehensive review of AI in cytology practice along with best practice recommendations and legal considerations. Additionally, the cytology global survey results highlighting current AI practices by various laboratories, as well as current attitudes, are reported.

Virtual microscopy in cytotechnology education: Application of knowledge from virtual to glass.

BACKGROUND: Virtual microscopy (VM) is a technology in which the glass slides are converted into digital images. The main objective of this study is to determine if cellular morphology, learned through virtual microscopy, can be applied to glass slide screening. MATERIALS AND METHODS: A total of 142 glass slides (61 teaching and 81 practice) of breast, thyroid, and lymph node fine needle aspiration body sites were scanned with a single focal plane (at 40X) using iScanCoreo Au (Ventana, Tuscan, AZ, USA, formerly known as BioImagene, California, USA). Six students including one distant student used these digital images to learn cellular morphology and conduct daily screening. Subsequently, all the students were tested on 10 glass slides using light microscopy (LM). At the end of the study, the students were asked to respond to an online survey on their virtual microscopy experience. The glass slide screening test scores of the participating students who were taught through VM and tested on glass slides (VMLM group) were compared with the last three classes of students who were taught through LM and tested on glass slides (LMLM group). RESULTS: A non-parametric statistical analysis indicated no difference (P = 0.20) in the glass screening test scores between VMLM (median = 93.5) and LMLM groups (median = 87). The survey indicated that the annotated teaching slides and access to the VM, off campus, were well appreciated by the students. CONCLUSIONS: Although the students preferred LM, they were able to apply the cytological criteria learned through VM to glass slide screening. Overall, VM was considered a great teaching tool.

Initial Assessments of E-Learning Modules in Cytotechnology Education.

BACKGROUND: Nine E-learning modules (ELMs) were developed in our program using Articulate software. This study assessed our cytotechnology (CT) students' perceptions on the content of the ELMs, and the perceived influence of the ELMs on students' performance during clinical rotations. SUBJECTS AND METHODS: All CT students watched nine ELMs before the related classroom lecture and group discussion. Following that, students completed nine preclinical rotation surveys. After their clinical rotations, students completed nine postclinical rotation surveys. RESULTS: Statements on the content of the ELMs regarding the quality of the video and audio, duration, navigation, and the materials presented, received positive responses from the majority of the students. While there were a few disagreements and neutral responses, most of the students responded positively saying that the ELMs better prepared them for their role, as well as helped them to better perform their roles during the clinical rotation. The majority of the students recommended developing more EMLs for cytology courses in the future. CONCLUSIONS: This study has given hope that the ELMs have potential to enhance our online curriculum and benefit students, within the United States and internationally, who have no easy access to cytology clinical laboratories for hands-on training.

Digital Applications in Cytopathology: Problems, Rationalizations, and Alternative Approaches.

OBJECTIVE: The aim of this work was to raise awareness of problems using digital applications for examining, teaching, and applying telecytology at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia; University of Nebraska Medical Center (UNMC), Omaha, NE, USA; and University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA. The objective was to rationalize problems and propose alternative digital approaches. STUDY DESIGN: We sought to identify solutions to improve the following: (a) interpretive examination scores at KAMC for complex cytological templates (i.e., high-grade squamous intraepithelial lesions [HSIL]) when using static digital images (SDI) of cells in regions of interest (ROI); (b) visualization of cells in 3D clusters when teaching at UNMC using 2D and 3D whole-slide imaging (WSI); and (c) visualization of cells through streaming telecytology at UPMC. RESULTS: Composite SDI (CSDI) improved test scores for complex interpretations (i.e., HSIL) by converging diagnostic criteria from multiple ROI. Multiplane focusing through z-stacked WSI facilitated the teaching of cytological entities characterized by 3D cell clusters and consultative telecytology through robotic cell analysis. CONCLUSIONS: Adequately visualized cytomorphology and multiplane focusing are essential for virtual cytopathology examinations, teaching, or consultative telecytology. Visualization of diagnostic criteria through 2D or 3D imaging is critical. Panoptiq panoramic WSI with integrated z-stacked video clips enables optimal applied telecytology.

Cervical cancer prevention for all the world's women: genuine promise resides in skilled quality management rather than novel screening approaches.

The debate over the best route for cervical cancer prevention in developing countries may be considered part of a larger debate over whether the global health community has become enamored with the promise of new approaches at the expense of delivering available preventives today. Pap screening, which is feasible anywhere cervical screening is appropriate, is the only intervention currently available for the prevention of cervical cancer in developing countries, and the Pap test will be an essential component of future novel preventive approaches. Cervical cancer vaccination, the long-term effectiveness of which is uncertain, will not eliminate screening requirements and is currently not affordable in developing countries. Root cause analyses, which may appropriately inform the best routes for improving health in developing countries, document that failures of cervical cancer prevention efforts are not attributable to factors specific to the Pap test but to lapses in programmatic quality management to which all screening tests are vulnerable. The genuine promise of cervical cancer prevention for all the world's women therefore resides in skilled quality management rather than novel screening approaches. We propose a global consensus policy by which Pap screening services will be provided in any setting where cervical screening is appropriate but unavailable, with consideration given to novel preventive approaches as they mature. Opportunity costs, borne by the underserved, are associated with prioritizing research on new approaches in any setting where established preventives are feasible but unavailable.

Interprofessional Education in Allied Health Using Virtual Technologies.

BACKGROUND: Interprofessional education (IPE) is becoming increasingly prevalent in health science education, with the goal of preparing students to work collaboratively in teams within the healthcare environment. Students in our cytotechnology and radiation therapy (RT) programs used virtual technologies to demonstrate their professions using case studies. The purpose of this activity was to see if our students' knowledge of each other's professions and educational technologies increased and if the students had a better understanding of how they would work together in a healthcare team. METHODS: Participants included four cytotechnology students and five RT students. All were given a presurvey to determine their level of knowledge about each other's profession. The cytotechnology students presented cases involving gynecologic and lung cancers using virtual microscopy and explained how they screen slides and interpret cellular changes. The RT students explained how they would treat these same patients using the Virtual Environment Radiotherapy Training system (VERT), showing the cytotechnology students how the beam is guided to the exact spot for treatment. After the IPE activity, all participants were given a post-survey to determine their levels of understanding. RESULTS: The results indicated that the IPE activity increased the level of understanding regarding each other's professions and how they each fit together in the role of patient care. CONCLUSIONS: IPE activities, even on a small scale with two professions in the same college, can improve knowledge and collaboration between professions. More of these activities should be conducted for effective healthcare teams and improved patient outcomes.

Inception and Development of the Papanicolaou Stain Method.

OBJECTIVE: Cytodiagnoses of specific malignancies are enabled through analyses of abnormal nuclear chromatin and cytoplasmic features in stained cells. AIM: The objective of this work was to explore the inception, development, and chemistry of the Pap stain method introduced in 1942 by Dr. G.N. Papanicolaou. STUDY DESIGN: To achieve this, we carried out a review of the English literature. RESULTS: Between 1914 and 1933, Papanicolaou first analyzed vaginal squamous cells in guinea pigs and later in human vaginal fluid samples using hematoxylin and eosin with limited color reactions, correlating the cell-type morphology with endocrinology and histology. The 5-dye Pap stain method evolved through 2 salient phases. The first, between 1933 and 1942, saw the introduction of alcohol-ether fixation and aqueous waterblue staining to enhance cellular transparency, aiding the distinction of cervical cancer cells from benign cells, with quantitative and qualitative assessment of squamous cell maturity. The second phase, between 1942 and 1960, saw the introduction and refinement of various alcoholic cytoplasmic counterstaining schemes with orange G and EA (light green, Bismarck brown, eosin) and phosphotungstic acid, allowing wider ranges of polychromasia and further enhancing cellular visualization, facilitating the distinction of cell types and improving diagnostic confidence. CONCLUSIONS: Development of the Pap stain method followed specific historical and scientific events. The staining method evolved following incremental improvements in cellular transparency achieved through tailored cellular fixation and cytoplasmic staining using variable dye and pH combinations.

Online education in cytotechnology programs: a pilot study.

INTRODUCTION: The University of Nebraska Medical Center's cytotechnology program has received requests for an on-line program. The purpose of this study is to demonstrate that on-line education with virtual microscopy (VM) achieves similar screening and interpretation skills as traditional teaching methods using light microscopy (LM). MATERIALS AND METHODS: The pilot phase was conducted using the first two courses in the program. The students were divided into two groups; traditional and virtual. The virtual group replaced LM with VM, while the traditional group utilized traditional teaching methods. At the end of the two courses, the virtual group was shown how to use LM and was given glass slide examinations. RESULTS: The mean of the female genital tract (FGT) screening quizzes and exams of the traditional group was 92.5; the mean for the virtual group was 86.8. For the respiratory tract (RT) course, the traditional group had a mean of 96 for their screening exams while the virtual group's was 85.3. The glass slide examinations (FGT Mean = 98, RT Mean = 95.3) given to the virtual group at the end of the pilot study demonstrated their ability to apply screening and interpretation skill learned from VM to LM. CONCLUSION: The study concludes that screening and interpretation skills of the traditional and virtual groups were similar. It appears possible to train students using VM as the sole method of teaching. The study will be extended to another cohort of students using the entire curriculum to further demonstrate the soundness of these results.

Utilization of virtual microscopy in cytotechnology educational programs in the United States.

BACKGROUND: Our cytotechnology (CT) program has been utilizing virtual microscopy (VM) as an adjunct educational resource since 2011. AIMS: The aim of this study was to identify the utilization of VM in other CT programs across the United States (US). SUBJECTS AND METHODS: A cover letter was sent to the program directors of all accredited CT programs in the US (excluding our program), requesting their participation in an online survey. After 2 days, the participants were sent an online link to the survey. The survey results were analyzed using descriptive statistics. RESULTS: There were a total of 25 respondents to the survey. Among the 25, three CT programs use VM. Two of the three programs have been using VM for <2 years while another program for "2-4" years. The respondents found that VM's side-by-side comparison feature helped to demonstrate differences between diagnoses and preparation methods, and VM helped to preserve the important slides by digitizing them. Respondents believed that teaching with glass slides was very important. The reasons for not using VM were that VM is expensive and time-consuming to incorporate into the program, and lack of manpower resources to create digitized teaching files. CONCLUSIONS: The CT programs that use VM found it to be a valuable educational tool. Even though many were not using VM, responses from the survey indicated they will likely use it in the future.

Coming to terms with Vietnam: the Viet/American Cervical Cancer Prevention Project.

The Viet/American Cervical Cancer Prevention Project embraces a dual mission. We seek to develop sustainable, cost-effective cervical cancer prevention services for women in Vietnam. Because the problem of cervical cancer in Vietnam is in part a legacy of the Second Indochinese War, we also seek to examine obstacles to reconciliation by presenting what most acknowledge to be a remedy in advance of what some will perceive to be an accusation. Certain research and commercial interests have produced obstacles to our dual mission in Vietnam. The Alliance for Cervical Cancer Prevention, supported by the Bill and Melinda Gates Foundation, has failed to endorse Pap screening for developing countries and is conducting clinical trials which may further disaffect medically underserved groups. Visual screening techniques combined with immediate ablative treatment methods are incompatible with the requirements of "first do no harm." Because the Pap smear will probably be a component of any future human papillomavirus (HPV)-based or visual- based screening programs, it serves the interests of those promoting noncytologic screening methods to also support the development of Pap screening services. Research on HPV screening in developing countries raises concerns of commercial exploitation. Because Pap screening is feasible wherever cervical screening is appropriate, it is inappropriate to delay the development of Pap screening services pending research into HPV vaccines or alternative screening technologies. Quality management is the point at which public health and diagnostic pathology intersect and will remain an indispensable element of cervical screening programs irrespective of the screening test(s) eventually used. Pap screening in developing countries is an ethical imperative without a substantial political constituency and will benefit from the engagement of organized cytology.

Investigation of scanning parameters for thyroid fine needle aspiration cytology specimens: A pilot study.

BACKGROUND: Interest in developing more feasible and affordable applications of virtual microscopy in the field of cytology continues to grow. AIMS: The aim of this study was to investigate the scanning parameters for the thyroid fine needle aspiration (FNA) cytology specimens. SUBJECTS AND METHODS: A total of twelve glass slides from thyroid FNA cytology specimens were digitized at ×40 with 1 micron (µ) interval using seven focal plane (FP) levels (Group 1), five FP levels (Group 2), and three FP levels (Group 3) using iScan Coreo Au scanner (Ventana, AZ, USA) producing 36 virtual images (VI). With an average wash out period of 2 days, three participants diagnosed the preannotated cells of Groups 1, 2, and 3 using BioImagene's Image Viewer (version 3.1) (Ventana, Inc., Tucson, AZ, USA), and the corresponding 12 glass slides (Group 4) using conventional light microscopy. RESULTS: All three raters correctly identified and showed complete agreement on the glass and VI for: 86% of the cases at FP Level 3, 83% of the cases at both the FP Levels 5 and 7. The intra-observer concordance between the glass slides and VI for all three raters was highest (97%) for Level 3 and glass, same (94%) for Level 5 and glass; and Level 7 and glass. The inter-rater reliability was found to be highest for the glass slides, and three FP levels (77%), followed by five FP levels (69.5%), and seven FP levels (69.1%). CONCLUSIONS: This pilot study found that among the three different FP levels, the VI digitized using three FP levels had slightly higher concordance, intra-observer concordance, and inter-rater reliability. Scanning additional levels above three FP levels did not improve concordance. We believe that there is no added benefit of acquiring five FP levels or more especially when considering the file size, and storage costs. Hence, this study reports that FP level three and 1 µ could be the potential scanning parameters for the thyroid FNA cytology specimens.

Optimal z-axis scanning parameters for gynecologic cytology specimens.

BACKGROUND: The use of virtual microscopy (VM) in clinical cytology has been limited due to the inability to focus through three dimensional (3D) cell clusters with a single focal plane (2D images). Limited information exists regarding the optimal scanning parameters for 3D scanning. AIMS: The purpose of this study was to determine the optimal number of the focal plane levels and the optimal scanning interval to digitize gynecological (GYN) specimens prepared on SurePath™ glass slides while maintaining a manageable file size. SUBJECTS AND METHODS: The iScanCoreo Au scanner (Ventana, AZ, USA) was used to digitize 192 SurePath™ glass slides at three focal plane levels at 1 µ interval. The digitized virtual images (VI) were annotated using BioImagene's Image Viewer. Five participants interpreted the VI and recorded the focal plane level at which they felt confident and later interpreted the corresponding glass slide specimens using light microscopy (LM). The participants completed a survey about their experiences. Inter-rater agreement and concordance between the VI and the glass slide specimens were evaluated. RESULTS: This study determined an overall high intra-rater diagnostic concordance between glass and VI (89-97%), however, the inter-rater agreement for all cases was higher for LM (94%) compared with VM (82%). Survey results indicate participants found low grade dysplasia and koilocytes easy to diagnose using three focal plane levels, the image enhancement tool was useful and focusing through the cells helped with interpretation; however, the participants found VI with hyperchromatic crowded groups challenging to interpret. Participants reported they prefer using LM over VM. This study supports using three focal plane levels and 1 µ interval to expand the use of VM in GYN cytology. CONCLUSION: Future improvements in technology and appropriate training should make this format a more preferable and practical option in clinical cytology.

Systems analysis of real-world obstacles to successful cervical cancer prevention in developing countries.

Papanicolaou screening is feasible anywhere that screening for cervical cancer, the leading cause of cancer-related death among women in developing countries, is appropriate. After documenting that the Vietnam War had contributed to the problem of cervical cancer in Vietnam, we participated in a grass roots effort to establish a nationwide cervical cancer prevention program in that country and performed root cause analyses of program deficiencies. We found that real-world obstacles to successful cervical cancer prevention in developing countries involve people far more than technology and that such obstacles can be appropriately managed through a systems approach focused on programmatic quality rather than through ideological commitments to technology. A focus on quality satisfies public health goals, whereas a focus on technology is compatible with market forces.