Interinstitutional consultation in fine-needle aspiration cytopathology: a study of 742 cases

Second opinion for pulmonary and pleural cytology is valuable for patient care

INTRODUCTION

Thoracic cytology can be challenging due to limited procured material or overlapping morphology between benign and malignant entities. In such cases, expert consultation might be sought. This study aimed to characterize all pulmonary and pleural cytology consult cases submitted to our practice and provide recommendations on approaching difficult cases.

MATERIALS AND METHODS

All thoracic (pulmonary and pleural) cytology cases submitted for expert consultation to the University of Michigan (MLabs) from 2013 to mid-2022 were reviewed. Cases where cytology was only part of a hematopathology or surgical pathology consult were excluded. Patient demographics, specimen location, procedure performed, referring diagnosis, and our diagnoses were recorded for each case. Diagnoses were categorized according to the Papanicolaou Society of Cytopathology recommendations for pulmonary and effusion cytology. Discordant diagnoses were stratified as major or minor. Data was analyzed using chi-square analysis and logistic models.

RESULTS

We received 784 thoracic cytology consult cases, including 530 exfoliative samples and 307 fine-needle aspirations. The most common anatomic locations sampled were the bronchial wall (n = 194, 23%), lung nodule (n = 322, 38%), and pleura (n = 296, 35%). 413 cases had a diagnostic discrepancy (48.3%), with 274 (66%) minor and 139 (34%) major discrepancies. By location, pleural effusion specimens had the highest probability of a discrepant diagnosis (P = 0.003). By specimen type, fine-needle aspiration samples were significantly more likely to have a discrepant diagnosis (P = 0.06).

CONCLUSION

Nearly half of the thoracic cytology cases submitted for expert second opinion had diagnostic discrepancies. Consequently, consulting a tertiary medical care center with cytopathology expertise for challenging thoracic cytology diagnoses is beneficial.

Digital Examination of LYmph node CYtopathology Using the Sydney system (DELYCYUS): An international, multi-institutional study

BACKGROUND

After a series of standardized reporting systems in cytopathology, the Sydney system was recently introduced to address the need for reproducibility and standardization in lymph node cytopathology. Since then, the risk of malignancy for the categories of the Sydney system has been explored by several studies, but no studies have yet examined the interobserver reproducibility of the Sydney system.

METHODS

The authors assessed interobserver reproducibility of the Sydney system on 85 lymph node fine-needle aspiration cytology cases reviewed by 15 cytopathologists from 12 institutions in eight different countries, resulting in 1275 diagnoses. In total, 186 slides stained with Diff-Quik, Papanicolaou, and immunocytochemistry were scanned. A subset of the cases included clinical data and results from ultrasound examinations, flow cytometry immunophenotyping, and fluorescence in situ hybridization analysis. The study participants assessed the cases digitally using whole-slide images.

RESULTS

Overall, the authors observed an almost perfect agreement of cytopathologists with the ground truth (median weighted Cohen κ = 0.887; interquartile range, κ = 0.210) and moderate overall interobserver concordance (Fleiss κ = 0.476). There was substantial agreement for the inadequate and malignant categories (κ = 0.794 and κ = 0.729, respectively), moderate agreement for the benign category (κ = 0.490), and very slight agreement for the suspicious (κ = 0.104) and atypical (κ = 0.075) categories.

CONCLUSIONS

The Sydney system for reporting lymph node cytopathology shows adequate interobserver concordance. Digital microscopy is an adequate means to assess lymph node cytopathology specimens.

A small-scale experimental study of breast FNA consultation on the internet using Panoptiq

INTRODUCTION

To test the potential for cytopathology consultation using Panoptiq (ViewsIQ, Richmond, BC, Canada; this is a new type of whole-slide image that is made manually and incorporates video content), we investigated its application in the cytopathological diagnosis of cases that were difficult to diagnose by breast fine-needle aspiration (FNA).

MATERIALS AND METHODS

Panoptiq files were created from liquid-based cytology slides prepared by the BD CytoRich Red (BD, Franklin Lakes, NJ) method. The slides were prepared from 23 consecutive samples of breast FNA that had been diagnosed as atypical or suspicious by the Hokkaido Cancer Center, Hokkaido, Japan. Nine volunteer reviewers, who were provided with the URL of the Panoptiq file, the original cytopathological diagnosis, and the clinical information, were asked to classify the cytopathological diagnosis of each case into 4 diagnostic categories (benign, atypical, suspicious, or malignant). We examined the consultation benefit (CB)-how much closer the reviewer's cytopathology diagnosis came to the final histopathological diagnosis than the original cytodiagnosis. The CB scoring system was decided in advance.

RESULTS

All 9 reviewers showed a positive total CB score and 2 reviewers showed a significantly higher CB score (Wilcoxon's signed rank test). The representative diagnosis (ie, the most frequently rendered diagnosis in each case) also showed a significant CB.

CONCLUSIONS

Our small-scale experimental study, in which Panoptiq was used in the diagnosis of cases that were difficult to diagnose definitively by breast FNA, revealed a positive CB score by every reviewer and the representative diagnosis showed a significant CB. The study suggests that Panoptiq could be used for cytopathology consultation.

Improved cytodiagnostics and quality of patient care through double reading of selected cases by an expert cytopathologist

Double reading may be a valuable tool for improving the quality of patient care by restoring diagnostic errors before final sign-out, but standard double reading would significantly increase costs of pathology. The aim of this study was to assess the added value of routine double reading of defined categories of clinical cytology specimens by specialized cytopathologists. Specialized cytopathologists routinely re-diagnosed blinded defined categories of clinical cytology specimens that had been signed out by routine pathologists from January 2012 up to December 2013. Major and minor discordance rates between initial and expert diagnoses were determined, and both diagnoses were validated by comparison with same-site histological follow-up. Initial and expert diagnoses were concordant in 131/218 specimens (60.1 %). Major and minor discordances were present in 28 (12.8 %) and 59 (27.1 %) specimens, respectively. Pleural fluid, thyroid and urine specimens showed the highest major discordance rates (19.4, 19.2 and 16.7 %, respectively). Histological follow-up (where possible) supported the expert diagnosis in 95.5 % of specimens. Our implemented double reading strategy of defined categories of cytology specimens showed major discordance in 12.8 % of specimens. The expert diagnosis was supported in 95.5 % of discordant cases where histological follow-up was available. This indicates that this double reading strategy is worthwhile and contributes to better cytodiagnostics and quality of patient care, especially for suspicious pleural fluid, thyroid and urine specimens. Our results emphasize that cytopathology is a subspecialization of pathology and requires specialized cytopathologists.

Evaluation of indeterminate thyroid cytology by second-opinion diagnosis or repeat fine-needle aspiration: which is the best approach?

OBJECTIVE

This study investigated a published series evaluating the role of second-opinion diagnosis (SOD) or repeat fine-needle aspiration cytology (RFNA) for indeterminate thyroid aspirates.

STUDY DESIGN

Twenty-three studies were selected and the following parameters were analyzed: disagreement between SOD or RFNA and the original diagnosis (OD), reclassification of OD according to the Bethesda system for reporting thyroid cytopathology, the rate of definitive diagnosis and the diagnostic performance of SOD and RFNA.

RESULTS

7,154 thyroid FNAs were retrieved from 9 studies that investigated the role of SOD, including 1,048 (14.6%) cases originally reported as indeterminate. The 14 studies that analyzed the role of thyroid RFNA comprised 67,581 FNAs and included 7,246 (10.7%) indeterminate cases. A definitive diagnosis was achieved by SOD in 450 cases (42.9%) and RFNA in 1,645 cases (57.2%, p=0.0001). Based on cases with histological follow-up, SOD demonstrated significantly higher rates of positive predictive value and accuracy than RFNA (55.8 vs. 37.7%, p=0.0001; 67.4 vs. 56.0%, p=0.0034, respectively).

CONCLUSIONS

Both SOD and RFNA demonstrated an improvement in the diagnosis of initially indeterminate thyroid FNAs. RFNA achieved a definitive diagnosis for the majority of indeterminate cases. Regarding histological follow-up, SOD was shown to be more accurate than RFNA.

Incidence and malignancy rates of diagnoses in the bethesda system for reporting thyroid aspiration cytology: an institutional experience

BACKGROUND

The Bethesda System for Reporting Thyroid Cytopathology (BSRTC) uses six diagnostic categories to standardize communication of thyroid fine-needle aspiration (FNA) interpretations between clinicians and cytopathologists. Since several studies have questioned the diagnostic accuracy of this system, we examined its accuracy in our hospital.

METHODS

We calculated the incidences and malignancy rates of each diagnostic category in the BSRTC for 1,730 FNAs that were interpreted by four cytopathologists in Gangnam Severance Hospital between October 1, 2011, and December 31, 2011.

RESULTS

The diagnostic incidences of categories I-VI were as follows: 13.3%, 40.6%, 9.1%, 0.4%, 19.3%, and 17.3%, respectively. Similarly, the malignancy rates of these categories were as follows: 35.3%, 5.6%, 69.0%, 50.0%, 98.7%, and 98.9%, respectively. In categories II, V, and VI, there were no statistically significant differences in the ranges of the malignancy rates among the four cytopathologists. However, there were significant differences in the ranges for categories I and III.

CONCLUSIONS

Our findings suggest that institutions that use the BSRTC should regularly update their diagnostic criteria. We also propose that institutions issue an annual report of incidences and malignancy rates to help other clinicians improve the case management of patients with thyroid nodules.

Impact of a single-day multidisciplinary clinic on the management of patients with liver tumours

PURPOSE

Multidisciplinary cancer clinics may improve patient care. We examined how a single-day multidisciplinary liver clinic (mdlc) affected care recommendations for patients compared with the recommendations provided before presentation to the mdlc.

METHODS

We analyzed the demographic and clinicopathologic data of 343 patients assessed in the Johns Hopkins Liver Tumor Center from 2009 to 2012, comparing imaging and pathology interpretation, diagnosis, and management plan between the outside provider (osp) and the mdlc.

RESULTS

Most patients were white (n = 259, 76%); median age was 60 years; and 146 were women (43%). Outside providers referred 182 patients (53%); the rest were self-referred. Patients travelled median of 83.4 miles (interquartile range: 42.7-247 miles). Most had already undergone imaging (n = 338, 99%) and biopsy (n = 194, 57%) at the osp, and a formal management plan had been formulated for about half (n = 168, 49%). Alterations in the interpretation of imaging occurred for 49 patients (18%) and of biopsy for 14 patients (10%). Referral to the mdlc resulted in a change of diagnosis in 26 patients (8%), of management plan in 70 patients (42%), and of tumour resectability in 7 patients (5%). Roughly half the patients (n = 174, 51%) returned for a follow-up, and 154 of the returnees (89%) received treatment, primarily intraarterial therapy (n = 88, 57%), systemic chemotherapy (n = 60, 39%), or liver resection (n = 32, 21%). Enrollment in a clinical trial was proposed to 34 patients (10%), and 21 of the 34 (62%) were accrued.

CONCLUSIONS

Patient assessment by our multidisciplinary liver clinic had a significant impact on management, resulting in alterations to imaging and pathology interpretation, diagnosis, and management plan. The mdlc is an effective and convenient means of delivering expert opinion about the diagnosis and management of liver tumours.

The interobserver reproducibility of thyroid fine-needle aspiration using the UK Royal College of Pathologists' classification system

The overall interobserver reproducibility of thyroid fine-needle aspiration (FNA) has not been comprehensively assessed. A blinded 6-rater interobserver reproducibility study was conducted of 200 thyroid FNA cases using the UK System, which is similar to The Bethesda System for Reporting Thyroid Cytology: Thy1, nondiagnostic; Thy2, nonneoplastic; Thy3a, atypia, probably benign; Thy3f, follicular lesion; Thy4, suspicious of malignancy; and Thy5, malignant. There was good interobserver agreement for the Thy1 (κ = 0.69) and Thy5 (κ = 0.61), moderate agreement for Thy2 (κ = 0.55) and Thy3f (κ = 0.51), and poor agreement for Thy3a (κ = 0.11) and Thy4 (κ = 0.17) categories. Combining categories implying surgical management (Thy3f, Thy4, and Thy5) achieved good agreement (κ = 0.72), as did combining categories implying medical management (Thy1, Thy2, and Thy3a; κ = 0.72). The UK thyroid FNA terminology is a reproducible and clinically relevant system for thyroid FNA reporting. This study demonstrates that international efforts to harmonize and refine thyroid cytology classification systems can improve consistency in the clinical management of thyroid nodules.

Histologic diagnoses in persistently swollen cervical lymph nodes

BACKGROUND

Biopsy and histological examination of persistently enlarged cervical lymph nodes represent a major health care issue and have high impact on further clinical therapy. Tertiary health centers are faced with an increased demand for diagnostic workup to rule out malignancy. We performed a retrospective study from January 2000 to June 2008 to identify patients referred to us for diagnostic biopsy and to document the histopathological result.

METHODS

Patients with a diagnostic biopsy, but neither clinical signs of head and neck cancer nor other malignancies, were identified within the records. Patient characteristics and histopathological diagnosis were retrieved.

RESULTS

Three hundred twenty-six patients were identified (146 women, and 180 men). One hundred twenty-three patients (38%; 44 women, and 79 men) had a malignancy: 61 with metastatic disease and 62 with malignant lymphoma; the youngest was 15 years old and the oldest was 92 years old.

CONCLUSION

Persistently swollen cervical lymph nodes should trigger a thorough clinical examination and prompt biopsy for histopathological workup.

Recent trends in quality, patient safety, and error reduction in nongyn cytology

This article reviews recent trends in nongyn cytology with an emphasis on error reduction, second opinion, and critical diagnosis. Compared with the surgical pathology literature, there is only a limited number of reports addressing these topics in nongyn cytology. Discussion of the error literature in nongyn cytology is presented with the intent to better identify error-prone cytology cases that could prompt intradepartmental consultation or an outside cytology expert's second opinion. The cytology second-opinion literature is also reviewed with the recommendation that interinstitutional second opinions add value to patient care. Last, the recent concept of critical value (critical diagnosis) in cytopathology is presented. All these initiatives promote patient safety, improve quality, decrease errors, and benefit patients.