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

Does ROSE matter? Evaluation of final diagnostic, PD-L1 immunohistochemistry, and molecular testing yields of CT-guided lung biopsies performed before and after the onset of the COVID-19 pandemic

INTRODUCTION

The onset of the COVID-19 pandemic, with urgent implementation of safety protocols limiting the number of on-site personnel, essentially terminated the use of rapid on-site evaluation (ROSE) for computed tomography (CT)--guided lung biopsies at our institution. The diminished use of ROSE during the pandemic prompted us to reevaluate the potential value of ROSE for CT-guided lung biopsies.

MATERIALS AND METHODS

We retrospectively identified all CT-guided lung biopsies from 2017 to 2022. Associations between the use of ROSE, adequate diagnostic and ancillary testing (programmed death-ligand 1 immunohistochemistry and next-generation sequencing) outcomes, and other factors such as the number of passes performed and lesion size, were evaluated.

RESULTS

Nine hundred twelve CT-guided lung biopsies were performed from 2017 to 2022; 171 (19%) utilized ROSE. The use of ROSE had been steadily decreasing prior to the pandemic but was essentially eliminated with the onset of the pandemic. By univariable analysis, the employment of ROSE was more likely to be associated with an adequate final diagnosis (odds ratio = 2.14, 95% confidence interval: [1.24-3.70], P = 0.006) and successful molecular testing (odds ratio = 2.16, 95% confidence interval: [1.11-4.21], P = 0.024). However, those associations were not present in multivariable analyses that incorporated the number of passes performed or lesion size. There were no differences in diagnostic adequacy or ancillary testing yields when comparing the periods 2017-2019 and 2020-2022, despite declining use of ROSE.

CONCLUSIONS

If ROSE is not requested for CT-guided lung biopsies, proceduralists should err on the side of performing more, rather than fewer, passes, particularly for smaller lesions.

CT-guided bone biopsy using electron density maps from dual-energy CT

Computed tomography (CT) -guided bone biopsy is a diagnostic procedure performed on the musculoskeletal system with a high diagnostic yield and low complications. However, CT-guided bone biopsy has the disadvantage that it is difficult to confirm the presence of tumor cells during the biopsy procedure. Recently, the clinical benefits of dual-energy CT (DECT) over single-energy CT have been revealed. DECT can provide material decomposition images including calcium suppression images, and effective atomic number (Z_eff) and electron density (ED) maps. ED maps have been reported to indicate cellularity. A 61-year-old woman with a history of breast cancer surgery was admitted to our hospital and underwent a CT-guided bone biopsy of the right ilium using ED maps. As a result, she was diagnosed with breast cancer metastases of intertrabecular bone. A comparison of ED maps with a pathological specimen revealed that high ED values occurred exclusively in the tumor area with high cellularity. This study indicates that ED maps produced using DECT may have potential utility in the accurate identification of metastases with high cellularity in bone lesions.

Transthoracic Needle Biopsy: How to Maximize Diagnostic Accuracy and Minimize Complications

Although transthoracic needle biopsy (TTNB) was introduced for lung biopsy about 40 years ago, it is still mainstay of pathologic diagnosis in lung cancer, because it is relatively inexpensive and can obtain tissue regardless of the tumor-bronchus relationship. With several technological advances, proceduralists can perform TTNB more safely and accurately. Utilizing ultrasound-guided biopsy for peripheral lesions in contact with the pleura and rapid on-site evaluation during the procedure are expected to make up the weakness of TTNB. However, due to the inherent limitations of the percutaneous approach, the incidence of complications such as pneumothorax or bleeding is inevitably higher than that of other lung biopsy techniques. Thorough understating of each biopsy modality and additional technique are fundamental for maximizing diagnostic accuracy and minimizing the complications.

Evaluating triage protocols for endoscopic ultrasound-guided fine needle biopsies of the pancreas

INTRODUCTION

Pancreatic endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) acquires both direct smear and small core biopsy specimens. The triage protocols for pancreatic FNBs to cytopathology (CP) or gastrointestinal surgical pathology (GIP) are controversial and vary by institution.

MATERIAL AND METHODS

Pancreatic EUS-FNBs obtained with the SharkCore FNB were reviewed from January 2014 to June 2019. The specimen characteristics and pathology data, including tissue triage, were obtained from the electronic medical records. We assessed the diagnostic yield, defined as malignant, specific neoplastic, or benign, and the operating characteristics at the time of rapid on-site evaluation (ROSE) and final diagnosis.

RESULTS

We reviewed 324 pancreatic FNBs from 313 patients. Of the 324 FNBs, 260 (80%) obtained concurrent direct smear and core biopsy specimens, 30 (12%) of which were divided between CP and GIP. Of the 51 core-only specimens, 47 (92%) were reviewed by CP and 4 (8%) by GIP. ROSE improved the overall diagnostic yield by 10% and accuracy by 9%. When core specimens were reviewed independently, the diagnostic accuracy was 93% for CP (n = 248) and 100% for GIP (n = 33). All false-negative results of the CP-reviewed cores were due to sampling error. Concurrent smear review improved EUS-FNB performance, increasing the negative predictive value by 10% and accuracy by 3% compared with core review alone.

CONCLUSIONS

CP and GIP can accurately interpret pancreatic EUS-FNB specimens. However, triage of concurrent EUS-FNB-acquired smear and core specimens to CP may be most efficient as CPs are trained to assess adequacy at the time of ROSE, as well as interpret all parts of the biopsy, minimizing the risk of discordant pathology reports.

Role of cytotechnologists in rapid onsite adequacy assessment of cytology materials for diagnostic workup and specimen allocation for ancillary testing using a standardized protocol

INTRODUCTION

Data on the performance of cytotechnologists in assessing specimen adequacy of needle core biopsies (NCB) is scant and their role in specimen triaging for ancillary studies have not been well established.

MATERIALS AND METHODS

We retrospectively analyzed rapid onsite evaluation (ROSE) performed exclusively by cytotechnologists on 248 NCB and fine-needle aspiration (FNA) specimens. Overall adequacy and accuracy rates were determined by comparing to final diagnosis. We also reviewed the process of specimen allocation for ancillary testing to determine whether specimens were appropriately triaged at the time of ROSE.

RESULTS

Of the 248 cases, 222 (89.5%) were touch imprint and 26 (10.5%) were FNA smears. The overall adequacy rate was 73.4% (182 of 248). Concordance for "adequate" interpretation by ROSE with unequivocal malignant or benign diagnoses on final interpretation was 95.6%. The sensitivity, specificity, and accuracy of ROSE for a final "positive for malignancy" were 89.2% (95% CI 83.04% to 93.69%), 43.24% (95% CI 31.77% to 55.28%), and 73.87% (95% CI 67.57% to 55.28%), respectively. Cases with "positive for malignancy" on final diagnosis were "adequate" by ROSE in 89.1% (132 of 148) and "inadequate" in 10.8% (16 of 148), P < 0.0001. Ancillary tests were performed in 168 of 248 (67.7%); the majority were immunohistochemical stains for determining tumor subtype. Predictive biomarkers were performed successfully in 100% of metastatic breast cancers.

CONCLUSIONS

Cytotechnologists performed at a high level of competency in providing ROSE and allocating specimens for ancillary testing, which were performed successfully in the majority of cases. Implementation of a standardized protocol for tissue management/prioritization is of paramount importance to maximize tissue preservation and minimize wastage.

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.

Rapid On-Site Evaluation of Fine-Needle Aspiration by Non-Cytopathologists: A Systematic Review and Meta-Analysis of Diagnostic Accuracy Studies for Adequacy Assessment

OBJECTIVE

Rapid on-site evaluation (ROSE) has been shown to improve adequacy rates and reduce needle passes. ROSE is often performed by cytopathologists who have limited availability and may be costlier than alternatives. Several recent studies examined the use of alternative evaluators (AEs) for ROSE. A summary of this information could help inform guidelines regarding the use of AEs. The objective was to assess the accuracy of AEs compared to cytopathologists in assessing the adequacy of specimens during ROSE.

STUDY DESIGN

This was a systematic review and meta-analysis. Reporting and study quality were assessed using the STARD guidelines and QUADAS-2. All steps were performed independently by two evaluators. Summary estimates were obtained using the hierarchal method in Stata v14. Heterogeneity was evaluated using Higgins' I2 statistic.

RESULTS

The systematic review identified 13 studies that were included in the meta-analysis. Summary estimates of sensitivity and specificity for AEs were 97% (95% CI: 92-99%) and 83% (95% CI: 68-92%). There was wide variation in accuracy statistics between studies (I2 = 0.99).

CONCLUSIONS

AEs sometimes have accuracy that is close to cytopathologists. However, there is wide variability between studies, so it is not possible to provide a broad guideline regarding the use of AEs.

Cytotechnologist Performance for Screening Hürthle Cell Atypia in Indeterminate Thyroid Fine-Needle Aspirates

OBJECTIVES

We have previously shown that specimens diagnosed as containing Hürthle cells have a 12% chance of being malignant if they are classified as atypia of undetermined significance (AUS-HC). The identification of Hürthle cells by cytotechnologists (CTs) during screening can improve cytopathologist efficiency and may prevent diagnostic errors due to the oversights of focal findings. Here, we examine the performance of our institutional CTs when screening for Hürthle cell atypia in thyroid fine-needle aspiration (FNA) specimens.

STUDY DESIGN

Information on 8,814 thyroid cytopathology specimens was retrieved for a 10-year period. Specimens were screened by 1 of 11 CTs. A subsample of cases was categorized either as AUS-HC or suspicious for Hürthle cell neoplasm.

RESULTS

AUS-HC screening diagnoses were more likely to be downgraded to benign but less likely to be upgraded compared to AUS diagnoses with nuclear or microfollicular atypia. AUS-HC represents almost all papillary thyroid carcinoma (PTC) screening diagnoses downgraded to the AUS category, which suggests that even low levels of Hürthle cell atypia can result in PTC being included in the differential diagnosis.

CONCLUSION

Overall, there are few major discrepancies between CT and pathologist diagnoses for specimens containing Hürthle cell atypia.