Cytotechnologist-attended on-site evaluation of adequacy for fine-needle aspiration of bone and soft tissue neoplasms

Fine-needle aspiration biopsy for the diagnosis of bone and soft tissue lesions: a systematic review and meta-analysis

INTRODUCTION

The workup of musculoskeletal (MSK) lesions utilizes a range of diagnostic tests including incisional biopsy, core needle biopsy, and fine-needle aspiration (FNA). FNA is the most cost-effective and least invasive biopsy method, but variation in its reported diagnostic performance has constrained its use for MSK lesions. Herein, we undertake a meta-analysis to clarify the diagnostic performance of FNA for bone and soft tissue lesions.

MATERIALS AND METHODS

A systematic search was run in MEDLINE, EMBASE, and CINAHL. Included studies were aggregated for pooled estimates of adequacy, accuracy, and sensitivity/specificity for all MSK lesions as well as bone and soft tissue independently. Analysis of heterogeneity and risk of bias were assessed across studies. Covariate subgroup analyses were attempted to investigate potential influences on diagnostic accuracy.

RESULTS

Twenty-five articles met inclusion criteria, representing 4604 FNAs. Adequacy was 92.3% (range: 59.2%-98.0%, S = 9.4%), and sensitivity/specificity for the nature (malignant or benign) of the lesion was 95.6% (95% CI: 94.5%-96.5%) and 96.9% (95% CI: 95.9%-97.7%). FNA was 75.8% accurate (range: 42.5%-99.3%, S = 17.3%) for definitive diagnosis. FNA provides higher accuracy for benign versus malignant nature in bone lesions but achieves a definitive diagnosis more frequently in soft tissue lesions.

CONCLUSIONS

The results of this meta-analysis support the expanded use of FNA in the diagnostic workup of bone and soft tissue lesions, particularly in light of a sensitivity and specificity comparable to incisional and core needle biopsy.

Results from the 2019 American Society of Cytopathology survey on rapid on-site evaluation-Part 1: objective practice patterns

INTRODUCTION

Rapid on-site evaluation (ROSE) is a service provided by cytologists that helps ensure specimen adequacy and appropriate triage for ancillary testing. However, data on the current usage patterns across different practice settings have been lacking.

MATERIALS AND METHODS

To obtain an accurate and timely assessment of the current state of practice of ROSE, a 14-question online survey was constructed by the Clinical Practice Committee of the American Society for Cytopathology. The survey was available to the membership of the American Society for Cytopathology for a 3-week period in early 2019.

RESULTS

A total of 541 responses were received, including from 255 cytopathologists/pathologists, 261 cytotechnologists, 19 cytology resident/fellow trainees, and 6 others. ROSE was offered as a clinical service by 95.4% of the respondents, with telecytology for ROSE used in 21.9% of the practices. Endobronchial ultrasound-guided transbronchial needle aspiration was the procedure most frequently reported to use ROSE (mean, 59.1%; median, 70%). Cytotechnologists were involved in ROSE in most practices. The number of daily ROSE procedures correlated with the annual nongynecologic cytology volumes. Approximately 70% of ROSE procedures were reported to require >30 minutes, on average, for the cytologist.

CONCLUSIONS

The results from our survey of cytologists have shown that the reported practice patterns for the usage of ROSE vary considerably. The presented data can help inform future guideline recommendations and the implementation of ROSE in different clinical settings.

Cytologic rapid on-site evaluation of transthoracic computed tomography-guided lung needle biopsies: who should perform ROSE? A cross-institutional analysis of procedural and diagnostic outcomes

INTRODUCTION

Cytologic rapid on-site evaluation (ROSE) during minimally invasive biopsy procedures is an increasingly important service provided by cytopathology to increase diagnostic yield and appropriately triage cellular material. Although ROSE can be performed by cytopathologists, cytotechnologists, or cytopathology fellows, few studies have directly compared both procedural and diagnostic outcome measures among different ROSE personnel.

MATERIALS AND METHODS

We evaluated all transthoracic computed tomography (CT)-guided lung biopsies in which ROSE was performed during a 1-year period at 2 academic institutions with similar patient populations and procedural methods: Dartmouth-Hitchcock Medical Center (DHMC) (where ROSE is performed by cytopathologists) and the Beth Israel Deaconess Medical Center (BIDMC) (where ROSE is rendered by either cytotechnologists or cytopathology fellows).

RESULTS

A total of 273 CT-guided transthoracic lung biopsies (190 DHMC, 83 BIDMC) were analyzed. There was no major difference in procedure time with respect to ROSE personnel. The repeat procedure rate for nondiagnostic biopsies was similar at DHMC (cytopathologists) and BIDMC (cytotechnologists or cytology fellows) (2.1% versus 2.3%, P = 1.0). Adequacy rates for cytopathologists, cytotechnologists, and cytopathology fellows were comparable (P = 0.23). ROSE assessments by cytopathologists were more concordant with the final diagnosis (87%) than those by cytotechnologists (82%) or cytopathology fellows (79%); this difference was not statistically significant (P = 0.28).

CONCLUSIONS

ROSE procedural and diagnostic outcomes for transthoracic CT-guided lung biopsies were similar among cytopathologists, cytotechnologists, and cytopathology fellows.

Imprint cytopathology of core needle biopsies: a "first responder" role for cytotechnologists

INTRODUCTION

Imprint cytopathology (IC) of image-guided core needle biopsies (CNBs) is used to ensure adequate sampling. In our institution, cytotechnologists (CyTs) are the "first responders" for on-site adequacy assessment (OSAA) of image-guided CNBs. We report our experience with this expanded and relatively unexplored role for CyT.

MATERIALS AND METHODS

We reviewed all image-guided CNBs performed over a 12-month period that required OSAA. OSAA was provided primarily by CyT. Interpretation between all IC specimens and tissue diagnoses (concordance) and between adequate IC specimens and tissue diagnoses (accuracy) were analyzed. Performance was compared using the Fisher exact test. We retrospectively reviewed discrepant cases to deduce the reasons for discordance.

RESULTS

We evaluated 255 CNBs: 179 computed tomography-guided, 74 ultrasonography-guided, 2 endoscopy-guided. Lung (39%) followed by liver (16%) and lymph node (11%) were the most frequent sites of OSAA IC. Overall adequacy and accuracy rates were 80.8% and 87.9%, respectively, with a concordance rate of 81.2%. The performance for CyT alone, CyT/cytopathology fellow, and CyT/cytopathologist were comparable (P > 0.05). Review of discordant cases showed agreement with 91% of OSAA IC cases originally interpreted as inadequate, but with only 19% interpreted as adequate.

CONCLUSIONS

OSAA IC of CNBs expands the CyT's role in an effort to ensure adequate sampling. CyT performance was high in recognition of adequate versus inadequate IC slides when compared with the tissue. Reasons for discrepancy included sampling error and overinterpretation of atypia as being sufficient evidence of adequacy. Organ-specific cytologic criteria to assess adequacy are required to reduce interpretation error.

Accuracy of cytotechnologist evaluation of specimen adequacy and screening interpretation of malignancy in fine-needle aspiration of the liver

OBJECTIVE

To evaluate the performance of cytotechnologists in assessing the adequacy and accuracy of the preliminary diagnosis for fine-needle aspirates of the liver.

STUDY DESIGN

We retrospectively analyzed 10 years of data and found 589 cases of ultrasound-guided fine-needle aspiration (FNA) of the liver with on-site evaluation of adequacy (OSEA). All the OSEA were performed by the cytopathologist because OSEA of liver FNA is not performed by cytotechnologists at our institution at present. After OSEA, the material was seen by cytotechnologists who rendered an adequacy assessment and preliminary diagnosis. We calculated the adequacy and accuracy statistics and compared the performance of the cytotechnologists with the OSEA and final interpretation.

RESULTS

There was no statistically significant difference in adequacy downgrade rate for cytotechnologist versus cytopathologist assessment during the study period (5 vs. 3%, p = 0.06). A total agreement of 88% was noted in overall diagnosis with 97% agreement in malignant cases.

CONCLUSION

Cytotechnologists assess the adequacy of liver FNA accurately and there is therefore potential for them to perform OSEA for liver FNA.

Cytopathologic characteristics of epithelioid vascular malignancies

OBJECTIVES

Epithelioid hemangioendothelioma (EHE) and epithelioid angiosarcoma (EAS) are rare vascular neoplasms that share many morphological characteristics on histology but demonstrate different clinical behavior. Given the many reported clinical and morphological features shared between EAS and EHE, we examined all cases of EAS and EHE diagnosed primarily on fine needle aspiration (FNA) at our three institutions that were confirmed by a tissue diagnosis.

STUDY DESIGN

A total of 29 cases from 25 patients were identified: 15 EHE from 11 patients and 14 EAS from 14 patients.

RESULTS

Many cytomorphological features existed on a spectrum that overlapped considerably between EAS and EHE cases. Common features between the two entities include epithelioid morphology and eccentrically placed nucleus. Intracytoplasmic lumens (ICL), a morphological feature that may suggest vascular origin, can be found in both entities but are not always present.

CONCLUSIONS

Given the general absence of vascular cytomorphological features, such as ICL, the proper classification of these tumors depends on the successful use of immunoperoxidase markers such as factor VIII-related antigen, ERG, or CD31 as well as a high index of suspicion. The distinction between EAS and EHE on FNA alone is treacherous at best.