6 Challenging Cases for the Cytopathology Professional During Immediate Assessment. Are You Prepared?

Transcription

1 6 Challenging Cases for the Cytopathology Professional During Immediate Assessment. Are You Prepared? Donna Russell MS, CT(ASCP)HT Maria Friedlander MPA, CT(ASCP) 2011 Annual Meeting Las Vegas, NV AMERICAN SOCIETY FOR CLINICAL PATHOLOGY 33 W. Monroe, Ste Chicago, IL 60603

2 6 Challenging Cases for the Cytopathology Professional During Immediate Assessment. Are You Prepared? Update your knowledge of image-guided fine needle aspirations from cytotechnology professionals engaged in immediate assessment and specimen triage. Radiologic findings, clinical history and cytologic criteria will be presented from a variety of contemporary image-guided techniques. ;;Challenging cases from a variety of techniques will be discussed, along with ancillary testing. Techniques include endoscopic ultrasound-guided FNA, endobronchial ultrasound-guided FNA, Super Dimension bronchial FNA, Cat-scan image-guided FNA and ultrasound-guided fine needle aspiration. Enhance skills utilizing cytologic, radiologic and clinical findings during FNA immediate assessment and specimen triage. Recognize the importance of adequate sampling for appropriate specimen triage and present emerging tests and ancillary techniques. Identify challenging cases in the cytologic evaluation of FNAs requiring immediate assessment. FACULTY: Donna Russell MS, CT(ASCP)HT Maria Friedlander MPA, CT(ASCP) Entire Pathology Team Cytopathology 2.0 CME/CMLE Credits Accreditation Statement: The American Society for Clinical Pathology (ASCP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education (CME) for physicians. This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME). Credit Designation: The ASCP designates this enduring material for a maximum of 2 AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. ASCP continuing education activities are accepted by California, Florida, and many other states for relicensure of clinical laboratory personnel. ASCP designates these activities for the indicated number of Continuing Medical Laboratory Education (CMLE) credit hours. ASCP CMLE credit hours are acceptable to meet the continuing education requirements for the ASCP Board of Registry Certification Maintenance Program. All ASCP CMLE programs are conducted at intermediate to advanced levels of learning. Continuing medical education (CME) activities offered by ASCP are acceptable for the American Board of Pathology s Maintenance of Certification Program.

3 ASCP ASCT Workshop 2011 ASCP Annual Meeting Las Vegas, Nevada October 19 21, 2011 Challenging Cases for the Cytology Professional During Immediate Assessment: Are you prepared? Donna K. Russell MS, CT(ASCP)HT Supervisor, Cytopathology Residency/Fellowship Training University of Rochester Medical Center Maria A. Friedlander MPA, CT(ASCP) Lab Manager, Cytology Service Program Director, School of Cytotechnology Memorial Sloan-Kettering Cancer Center Notice of Disclosure In accordance with ACCME guidelines, any individual in a position to influence and/or control the content of this ASCP CME activity has disclosed all relevant financial relationships within the past 12 months with commercial interests that provide products and/or services related to the content of this CME activity. The individuals below has responded that he has no relevant financial relationships with commercial interests to disclose: Donna K. Russell MS, CT(ASCP)HT Maria A. Friedlander MPA, CT(ASCP) October 20, :00 PM to 5:50 PM 1

4 Educational Objectives Enhance skills utilizing cytologic, radiologic and clinical findings during FNA immediate assessment and specimen triage. Recognize the importance of adequate sampling for appropriate specimen triage and present emerging tests and ancillary techniques. Identify challenging cases in the cytologic evaluation of FNAs requiring immediate assessment.. Introduction Laboratories across the country are experiencing shifts in cytopathology volume. non-gynecologic cytology volumes are increasing across the country. Pap testing is on the decline. Image guided FNAs with immediate assessment and specimen triage are increasing in numbers improved patient care new imaging techniques are on the rise for FNA procedures October 20, :00 PM to 5:50 PM 2

5 How will the laboratory adjust to the demands of immediate assessment requests by clinicians? Cytopathologists will rely on CTs, residents, and fellows to play an important role in: immediate specimen assessment specimen triage Cytopathology professional will need to re- evaluate criteria from different sites for accurate immediate assessment and proper adjunctive testing Value of Specimen Adequacy Assessment Provides feedback on: need for additional passes facilitates triaging of specimen for ancillary studies (i.e. immuno studies, molecular studies, flow cytometry, microbiology, surgical biopsy) Preliminary diagnosis (by cytopathologist) facilitate rapid clinical decisions Reports show high concordance between on-site immediate diagnosis and relative to final cytopathology diagnosis (8%-100%) Time/cost savings Avoid repeat procedures (additional cost/expense for institution and patient) Adequate assessment performed by CT frees cytopathologist MD to perform other duties Customer satisfaction (clinician and patient) FNA dx within 24 hours of procedure Reduces patient anxiety Avoid repeat visit for inadequate specimens or to procure more material for additional studies and incurred costs October 20, :00 PM to 5:50 PM 3

6 Limitations Time consuming procedures Avg time for a MD to be present and provide specimen ADQ assessment reported between minutes timing of pages Time is money Immediate on-site interpretations insufficiently compensated by Medicare Cost of providing specimen assessment CT < MD Wotruba et al showed potential savings = $306, CT can only provide specimen adequacy not prelim interpretation Elements for Success Good aspirator (radiologist / clinician / surgeon / pathologist) Trained cytologist good smear preparations by cytologist Proper smearing and staining technique Proper fixation of other cytologic material knowledgeable with morphology of a variety of FNA sites competent to provide adequacy assessment Effective communication between operator and cytologist including: provision of clinical and radiological impression BEFORE procedure relevant clinical history (prior documented malignancy, therapy, other relevant disease) Minimize wasted time Timing of pages Share schedule of procedures October 20, :00 PM to 5:50 PM 4

7 Issues affecting success Sampling issues due to nature of lesion Small lesions Dense, fibrotic lesions Location of lesion (deep) Marked inflammatory or necrotic lesions Necrotic-centered lesions Vascular lesions Cystic lesions Poor technical specimen preparation Uneven smearing Inadequate air-drying for DQ smears Inappropriate fixation Issues affecting success (cont d) Training of cytologist may take time for cytologist to feel comfortable with this activity Working with Radiologists vs Surgeons provision of specimen ADQ during FNAs is new activity for cytologists who historically work independently with their microscopes must learn how to work and communicate effectively with other health care staff during operative procedures Pressure on CT by clinicians/radiologists to share what they think diagnosis is I know you can t say but what do you think? It happens we make a mistake and think a case is ADQ when it is not.usually rare October 20, :00 PM to 5:50 PM 5

8 Critical steps of FNA 1. Collection of pertinent clinical data 2. Needle sampling of abnormality 3. Specimen preparation and staining 4. Microscopic evaluation/interpretation 5. Communication and reporting TEAM Clinician Radiologist Pathologist October 20, :00 PM to 5:50 PM 6

9 Imaging Modalities Computerized axial tomography (Cat Scan/CT) Ultra-sound Endoscopic U/S guided Endobronchial U/S guided (EBUS) Fluoroscopy real-time imaging Electromagnetic Navigation Bronchoscopy (ENB) superdimension Who can provide specimen adequacy assessment? Cytopathologist Cytology fellow Cytotechnologist specimen adequacy ONLY NO preliminary interpretation / diagnosis October 20, :00 PM to 5:50 PM 7

10 CTs and FNA Specimen Adequacy Assessment? Burlingame O, Cibas E, Silverman S. 94% accuracy rate by CTs 2956/3154 unequivocally benign or malignant cytology cases for 10 CTs accuracy rate for liver FNAs (97%) vs kidney (90%) imaging method showed no effect on accuracy Wotruba A, Stewart J, Scheberl, Selvaggi SM. 98.8% concordance rate between CT and MD for ADQ assessments (based on 167 thyroid FNAs) 5 CTs and 3 MDs History reviewed prior to FNA and forwarded to MD CT calls MD for prelim dx ONLY on cases with increased chance of malignancy OR difficult cases (i.e. high cellularity, microfollicular arrangements, intranuclear inclusions observed) Redman R, Zalaznick H, Mazzaferri EL, Massoli NA. 97% MD specimen accuracy vs 93% CTs for thyroid FNAs Equipment & Supplies Required gauge or smaller needle Syringe (10 ml) Gauze Band- aids Local anesthetic (lidocaine) FNA gun Paperwork Test requisition form Time out checklist Procedure note form blocks) Microscope (dual-head nice for teaching!) Stains Slides (regular/charged slides) Pencil, pen, markers Cytology fixatives (and other fixatives if procuring material for ancillary studies) Cytolyt 95% Ethanol Formalin (core biopsies, cell RPMI, saline (Flow Cytometry) Containers to transport slides (slide holders, trays, etc.) Paper towels October 20, :00 PM to 5:50 PM 8

11 Stains for Immediate Assessment Diff Quik (DQ) Modified-Romanowsky stain Rapid procedure Requires air-drying Highlights cell architecture, background matrix material, organisms and cytoplasmic contents Reports that using a small fan to dry slides can reduce drying time as much as 70% Ultrafast Papanicolaou stain Others? October 20, :00 PM to 5:50 PM 9

12 Stains for Immediate Assessment Ultrafast Papanicolaou stain 90 second polychromatic stain transparent preparations and crisp nuclear details Re-hydration of air-dried smears Others? Common Ancillary Studies Performed on Cytology Material Immunocytochemistry Special stains (GMS, AFB) Microbiology Flow cytometry Electron microscopy Image analysis Cytogenetics Molecular diagnostic tests FISH PCR October 20, :00 PM to 5:50 PM 10

13 FNA Billing , performance of FNA immediate adequacy evaluation immediate adequacy evaluation of additional passes interpretation and report cell block immunochemical stains special stains Proper documentation required in report and medical record to bill appropriately! Consult with your compliance department! Use of Telecytology for Immediate Assessment October 20, :00 PM to 5:50 PM 11

14 Use of Telecytology for Immediate Assessment Reports of 97% - 100% diagnostic concordance between real-time on-site and telecytology interpretations Pros: Less time and travel commitment required by pathologist Minimal disruption to those viewing image Enhanced capability to have multiple simultaneous reviewers for consensus opinion, if required Issues with Telecytology Initial validation required individual performance interobserver variability diagnostic pitfalls unique to telecytology vs actual slide viewing User related issues field of view selection by on site user certain FNA sites may be more difficult to assess Hardware / Software / IT Network uncontrollable stage by remote viewer Workflow Cost October 20, :00 PM to 5:50 PM 12

15 P t II Ch ll i C Part II: Challenging Case Presentations (to be presented during workshop) October 20, :00 PM to 5:50 PM 13

16 ASCP-ASCT Workshop 2011 ASCP Annual Meeting October 2011 Challenging Cases for the Cytology Professional During Immediate Assessment: Are you prepared? Donna K. Russell MS, CT(ASCP)HT / Maria A. Friedlander MPA, CT(ASCP) References: 1. Burlingame O, Cibas E, Silverman S. Onsite adequacy evaluations performed by cytotechnologists: correlation with final cytopathology reports of 5793 image guided fine needle aspiration biopsies [abstract]. Cancer (Cancer Cytopathol) Suppl 2010;118: Wotruba A, Stewart J, Scheberl T, Selvaggi SM. Added value, decreased cost: the evolving role of the cytotechnologist for preliminary screening and triage of thyroid aspirates [E pub ahead of print]. Diagn Cytopatol Accessed August 29, Yang GC, Alvarez II. Ultrafast Papanicolaou stain: an alternative for fine needle aspiration cytology. Acta Cytol 1995;Jan-Feb;39(1): Baig MA, Fathallah L, Feng J, Husain M, Grignon DG, Al-Abbadi MA. Fast drying of fine needle aspiration slides using a hand hled fan: impact on turn around time and staining quality. CytoJournal 2006; Apr 19:3: Redman R, Zalaznick H, Mazzaferri, Massoli NA, The impact of assessing specimen adequacy and number of needle passes for fine-needle aspiration biopsy of thyroid nodules. Thyroid 2006; Jan 16: Layfield LJ, Bentz JS, Gopez EV. Immediate on-site interpretation of fine needle aspiration smears: a cost and compensation analysis. Cancer (Cancer Cytopathol) 2001; 93: Nasuti JF, Gupta PK, Baloch ZW. Diagnostic value and cost-effectiveness of on-site evaluation of fine-needle aspiration specimens: review of 5,688 cases. Diagn Cytopathol 2002; 27(1): Eedes CR, Wang HH. Cost-effectiveness of immediate specimen adequacy assessment of thyroid fine needle aspirations. Am J Clin Pathol 2004;121: Wu M, Burstein DE. Fine Needle Aspiration. Cancer Investigation 2004; 22: Papanicolaou Society of Cytopathology Task Force on Standards of Practice. Guidelines of the Papanicolaou Society of Cytopathology for fine needle aspiration procedure and reporting. Diagn Cytopathol 1997;17: Smola B, Jing X, Rasche R, Roh M, Micahel C, Davenport R, Knoepp S. Remote adequacy assessment of fine needle aspiration biopsy specimens via telepathology: a review of the success and inter-observer variability of 50 consecutive cases [abstract]. Cancer (Cancer Cytopathol) Suppl 2010;118: Wilbur DC. Digital cytology: current state of the art and prospects for the future. Acta Cytol 2011; 55(3): Kim B, Chhieng D, Crowe D, Jhala D, Jhala N, Wonokaur T, Eloubeidi MA, Eltoum IE. Dynamic telecytopathology has equivalent efficacy with on-site rapid cytology diagnosis for pancreatic carcinoma. Cytojournal 2006; 3: Kerr SE, Bellizzi AM, Stelow EB, Frierson HF Jr, Policarpio-Nicolas ML. Initial assessment of fine needle aspiration specimens by telepathology: validation for use in pathology resident faculty consultations. Am J Clin Pathol 2008;130(3): Alsharif M, Carlo-Demovich J, Massey C, Madory JE, Lewing D, Medina AM, Recavarren R, Houser PM, Yang J: Tlecytopathology for immediate evaluation of fine neelde aspiration specimens. Cancer Cytopathol 2010; 118: Heimann A, Maini G, Hwang S, Shroyer K, Singh M. Use of telecytology for the immediate assessment of CT guided and endoscopic FNA cytology: diagnostic accuracy, advantages and pitfalls. [E pub ahead of print]. Diagn Cytopatol Accessed August 29, Kim B, Chhieng D, Jhala N, Winokur T, Eloubeidi MA, Eltoum IE. Dynamic telecytopathology of on site rapid cytology diagnosis for pancreatic carcinoma. Cytojournal 2006; Dec11;3: Kerr SE, Bellizzi AM, Stelow EB, Frierson HR Jr, policarpio-nicolas ML. Initial assessment of fine neelde aspiration speciments by telepathology: validation for use in pathology resident faculty consultations. Am J Clin Pathol 2008;130: