Rapid on-site evaluation using telecytology: A major cancer center experience.

BACKGROUND: Rapid on-site evaluation (ROSE) with cytology preparations plays a critical role in minimally invasive procedures. The time spent by a pathologist performing ROSE is unpredictable and could be used for more cost-effective activities. The solution encountered by several institutions to address this issue is the use of telecytology (TC). This study analyzes the experience of using telecytology for ROSE in a major cancer center over a period of over 2 years. METHODS: A retrospective analysis of all remote TC evaluations for adequacy on fine needle aspiration (FNA) and touch preparations (TP) of core biopsies (CB) performed at a major cancer center was performed. The preliminary adequacy assessment was then compared to the adequacy assessment at final diagnosis. RESULTS: A total of 12 949 adequacy assessments were analyzed. The most common sites biopsied in our institution were lymph node, lung, and liver. There were 7725 adequacy assessments for CB (59.7%), while adequacy assessment for FNA specimens represented 40.3% (n = 5224) of the total number of specimens evaluated by ROSE. Perfect concordance between initial adequacy assessment and the adequacy assessment at final cytologic diagnosis was 93% (12 049/12 949). The final diagnosis adequacy upgrade rate was 6.7% (n = 863), and the adequacy downgrade (a specimen considered adequate on-site that was determined to be nondiagnostic on final examination) was 0.3% (n = 37). CONCLUSIONS: TC can be easily implemented with the current technologies available. It is cost-effective and allows for better patient care with a more efficient use of the pathologist's time and laboratory resources.

Novel Modification of HistoGel-Based Cell Block Preparation Method: Improved Sufficiency for Molecular Studies.

CONTEXT: - Cell block preparation methods vary substantially across institutions and are frequently suboptimal. The growing importance of biomarker testing in the era of targeted therapies makes optimization of cell block preparation critically important. OBJECTIVE: - To develop an improved cell block preparation method. DESIGN: - Ex vivo fine-needle aspirates and scrapes from surgically resected tumors were used to develop an improved HistoGel (Thermo Fisher Scientific, Waltham, Massachusetts)-based cell block preparation method. Cellularity yield with the new versus the standard method was assessed in ex vivo split samples and in consecutive clinical fine-needle aspirates processed before (n = 100) and after (n = 100) the new method was implemented in our laboratory. Sufficiency of cell block material for potential molecular studies was estimated by manual cell quantitation. RESULTS: - The key modification in the new method was pretreatment of the pelleted cells with 95% ethanol before the addition of HistoGel (HistoGel + ethanol method). In addition, we optimized the melting conditions of HistoGel and added a dark, inorganic marker to the cell pellets to highlight the desired level of sectioning during microtomy. Cell blocks from ex vivo split samples showed that the HistoGel + ethanol method yielded, on average, an 8.3-fold (range, 1-20) greater cellularity compared with the standard HistoGel-only method. After the switch from the standard HistoGel method to the modified method in our clinical practice, sufficiency of positive fine-needle aspirates for some molecular studies increased from 72% to 97% ( P = .002). CONCLUSIONS: - We describe a simple and readily adoptable modification of the HistoGel method, which results in substantial improvement in cell capture in cell blocks, leading to a significant increase in sufficiency for potential molecular and other ancillary studies.

Successful Secure High-definition Streaming Telecytology for Remote Cytologic Evaluation.

BACKGROUND: The use of minimally invasive procedures to obtain material for diagnostic purposes has become more prevalent in recent years. As such, there is increased demand for immediate cytologic adequacy assessment of minimally invasive procedures. The array of different locations in which rapid on-site evaluation (ROSE) is expected requires an ever-increasing number of cytology personnel to provide support for adequacy assessment. In our study, we describe the implementation process of a telecytology (TC) system in a high case volume setting and evaluate the performance of this activity. METHODS: We performed retrospectively an analysis of all consecutive remote TC ROSE evaluations obtained for 15 months. The specimens were evaluated using a TC system. The ROSE adequacy assessment obtained at the time of the procedure was compared to the final cytopathologist-rendered adequacy assessment when all the material was available for review, including the alcohol-fixed preparations. RESULTS: A total of 8106 distinct cases were analyzed. TC-assisted preliminary adequacy assessment was highly concordant with the final cytopathologist-rendered adequacy assessment. Perfect concordance or accuracy was at 93.1% (7547/8106). The adequacy upgrade rate (inadequate specimen became adequate) was 6.8% (551/8106), and the initial adequacy downgrade (adequate specimen became inadequate) was <0.1% (8/8106). CONCLUSIONS: The TC outcome demonstrates high concordance between the initial adequacy assessment and final cytopathologist-rendered adequacy assessment. Adequacy upgrades were minor but, more importantly, our results demonstrate a minimal adequacy downgrade. The process implemented effectively eliminated the need for an attending pathologist to be physically present onsite during a biopsy procedure.

Robotic Telecytology for Remote Cytologic Evaluation without an On-site Cytotechnologist or Cytopathologist: A Tale of Implementation and Review of Constraints.

BACKGROUND: The first satellite center to offer interventional radiology procedures at Memorial Sloan Kettering Cancer Center opened in October 2014. Two of the procedures offered, fine needle aspirations and core biopsies, required rapid on-site cytologic evaluation of smears and biopsy touch imprints for cellular content and adequacy. The volume and frequency of such evaluations did not justify hiring on-site cytotechnologists, and therefore, a dynamic robotic telecytology (TC) solution was created. In this technical article, we present a detailed description of our implementation of robotic TC. METHODS: Pathology devised the remote robotic TC solution after acknowledging that it would not be cost effective to staff cytotechnologists on-site at the satellite location. Sakura VisionTek was selected as our robotic TC solution. In addition to configuration of the dynamic robotic TC solution, pathology realized integrating the technology solution into operations would require a multidisciplinary effort and reevaluation of existing staffing and workflows. RESULTS: Extensively described are the architectural framework and multidisciplinary process re-design, created to navigate the constraints of our technical, cultural, and organizational environment. Also reviewed are the benefits and challenges associated with available desktop sharing solutions, particularly accounting for information security concerns. CONCLUSIONS: Dynamic robotic TC is effective for immediate evaluations performed without on-site cytotechnology staff. Our goal is providing an extensive perspective of the implementation process, particularly technical, cultural, and operational constraints. Through this perspective, our template can serve as an extensible blueprint for other centers interested in implementing robotic TC without on-site cytotechnologists.

Robotic Telecytology for Remote Cytologic Evaluation without an On-site Cytotechnologist or Cytopathologist: An Active Quality Assessment and Experience of Over 400 Cases.

BACKGROUND: The first satellite center to offer interventional radiology procedures at Memorial Sloan Kettering Cancer Center opened in October 2014. Two of the procedures offered, fine needle aspirations and core biopsies, required a rapid on-site cytologic evaluation of smears and biopsy touch imprints for cellular content and adequacy. The volume and frequency of such evaluations did not justify hiring on-site cytotechnologists, and therefore, a dynamic robotic telecytology (TC) solution was created. In this article, we provide data on our experience with this active implementation. Sakura VisionTek was selected as our robotic TC solution. METHODS: A retrospective analysis of all TC evaluations from this satellite site was performed. Information was collected on demographics, lesion location, imaging modality; a comparison of TC-assisted adequacy with final adequacy was also conducted. RESULTS: An analysis of 439 cases was performed over a period of 23 months with perfect correlation in 92.7% (407/439) of the cases. An adequacy upgrade (inadequate specimen becomes adequate) in 6.6% (29/439) of the cases. An adequacy downgrade (adequate specimen becomes inadequate), is near zero at 0.7% (3/439) of the cases. CONCLUSIONS: Dynamic robotic TC is effective for immediate evaluations performed without on-site cytotechnology staff. The overall intent of this article is to present data and concordance rates as outcome metrics. Thus far, such outcome metrics have exceeded our expectations. Our TC implementation shows high, perfect concordance. Adequacy upgrades are minor but more relevant and impressive is a near zero adequacy downgrade. Our full implementation has been so successful that plans are in place for configurations at future satellite sites.

Impact of touch preparations on core needle biopsies.

BACKGROUND: Touch preparations (TPs) can be performed for on-site adequacy assessment of core needle biopsies (CNBs). Although TPs can play a role in decreasing the number of nondiagnostic core biopsies, the impact of TPs on CNB has not been extensively evaluated. METHODS: Computerized tomography-guided CNBs performed in a tertiary cancer center were retrospectively identified. On-site adequacy assessment was performed in all cases. The matching TPs and CNBs were evaluated for diagnostic accuracy of the TP. The relation between the site of biopsy and the cellularity of the CNB was also analyzed. RESULTS: A total of 1100 CNB cases with associated TPs were identified over a 6-month period. Eighty-four cases (8%) showed marked differences in cellularity between CNB and TP, and 43 of these 84 cases (4.3%) showed the presence of diagnostic cells in either CNB or TP, but not in both. Lung was the biopsy site where CNB was most affected by loss of diagnostic cells. CONCLUSIONS: TP and CNB findings must be integrated to prevent a misdiagnosis. Lung CNBs were more frequently affected by performing TPs.

Predicting pulmonary adenocarcinoma outcome based on a cytology grading system.

BACKGROUND: Pulmonary adenocarcinoma (AD) has a variety of architectural patterns. Recently, a 3-tiered histological pattern-based grading system was developed for stage I lung AD, stratifying patients into low, intermediate, and high risk for recurrence. However, cytology may serve as the primary method for diagnosis in patients with inoperable disease. Attempts to correlate architecture between parallel cytological and histological preparations have not been successful. Therefore, we evaluated cytomorphologic features of previously histologically graded AD to identify features of potential prognostic significance. METHODS: One hundred and thirteen fine-needle aspirations with excised adenocarcinomas were reviewed. In the liquid-based preparation, we evaluated cell arrangements(flat sheets vs 3-D clusters vs single cells), nuclear features (size variability, shape, and contour),nucleoli (prominent or inconspicuous), presence of nuclear inclusions, chromatin (fine, coarse,or clumped), and quality of background. The features were tested by multivariate analysis to identify associations with histological grade and disease-free survival (DFS), and a cytological score was generated. RESULTS: Nuclear size, chromatin pattern, and nuclear contours showed a significant association with histological grade and DFS. These features were included in the composite cytological score (range,0-5). By grouping the cytological scores, we stratified the tumors into low (median DFS, 100%), intermediate(median DFS, 78%), and high (median DFS, 55%) rate of recurrence (P » .008). There was a good correlation with the histological grading system. CONCLUSIONS: In liquid-based preparations, distinctive cytological features of pulmonary adenocarcinoma correlate with levels of histological differentiation and can be combined into a score with prognostic significance.

Cytologic diagnosis of pulmonary adenocarcinoma with micropapillary pattern: does it correlate with the histologic findings?

Micropapillary adenocarcinoma is associated with poor-prognosis in several organs including the lung. The presence of small tight balls of neoplastic cells devoid of fibrovascular core in cytological preparations (micropapillary tufts) has been described as characteristic of micropapillary adenocarcinoma. In the lung, however, this criterion has not been validated. The cytological material of 46 cases of histologically proven pulmonary adenocarcinoma with a micropapillary component was compared to 33 cases with no micropapillary component to determine the specificity of micropapillary tufts for the histologic diagnosis of micropapillary adenocarcinoma. Other histologic patterns of invasive pulmonary adenocarcinomas (acinar, papillary, and solid) were also compared with patterns of neoplastic cell aggregates in cytological preparations. There were no significant differences in the distribution of micropapillary clusters between the two groups. The positive predictive value for the cytologic diagnosis of a micropapillary component in lung adenocarcinomas was of 64%. Similar findings were observed for other invasive patterns. Therefore, the detection of micropapillary tufts in cytology is not specific for the diagnosis of a pulmonary micropapillary adenocarcinoma in the lung.

Effectiveness of the Thin Prep Imaging System in the detection of adenocarcinoma of the gynecologic system.

BACKGROUND: The ThinPrep Imaging System (TIS) has been approved by the U.S. Food and Drug Administration for use to decrease the number of false-negative results in ThinPrep (TP) gynecologic specimens and increase cytotechnology productivity. Although the increased detection of squamous abnormalities using the TIS has been well documented, to the authors' knowledge, data regarding the impact of the TIS in the detection of glandular abnormalities is limited. The goal of the current study was to evaluate the effectiveness of the TIS in detecting glandular abnormalities in cervicovaginal specimens. METHODS: TIS evaluated TP tests with histologic confirmation of adenocarcinoma involving the gynecologic system were included in the current study. Two cytotechnologists independently reviewed the cases for the presence or absence of atypical glandular cells. Review results were correlated with initial cytologic and histologic diagnoses. RESULTS: A total of 124 cases met the criteria for inclusion in the current study. Seventy of these cases (56%) were found to contain atypical glandular cells on the TP slide. TIS was able to identify atypical cells in 97% of these cases (68 of 70 cases). Nine cases initially reported as benign were found to contain atypical glandular cells on secondary review. All but 1 of these cases contained atypical glandular cells detected by the TIS. The majority of these false-negative cases (6 of 9 cases) derived from endometrial adenocarcinoma. No cytologic evidence of a glandular abnormality was found in the 54 remaining cases. CONCLUSIONS: The TIS was found to be effective in identifying atypical glandular cells in specimens containing malignant glandular cells, leading to a full review of the slide.