Telecytology rapid on-site evaluation: Diagnostic challenges, technical issues and lessons learned

The Current and Future Impact of Lymph Node Fine-Needle Aspiration Cytology on Patient Care

Lymph node (LN) fine-needle aspiration cytology (FNAC) is a common diagnostic procedure for lymphadenopathies. Despite the qualities and potentialities of LN-FNAC, the number of possible pathologies and the variety of clinical contexts represent a challenge and require a continuous upgrading of the procedure according to the emerging clinical requests and new technologies. This study presents an overview of the current and future impact of LN-FNAC on the care of patients with lymphadenopathy.

Rapid on-site evaluation of fine-needle aspiration specimens using cytotechnologist-performed telecytology: Insights and advantages

With multiple health care centres expanding and implementing remotely controlled technologies, the role of cytopathology laboratories will become crucial in optimizing collection and assessment of small biopsy specimens for diagnosis and personalized treatment. Cytopathology services provide rapid assessments of samples obtained from fine-needle aspirations and occasionally core needle biopsies (analysed by touch imprints). Over the past few decades, the cost barrier for hospitals, especially small ones, to support a cytopathologist or cytotechnologist for rapid on-site evaluation (ROSE) has been reduced by the introduction of computerized microscopes that allow cytopathologists to perform ROSE without being present at the satellite laboratory (i.e. remotely). Utilization of the cytotechnologist's experience in ROSE alongside these technologies made it possible to perform ROSE with telecytology (ROSE-TC), which positively impacts diagnosis and treatment and also lowers the cost of care. The satellite laboratories that successfully implemented ROSE-TC operate with experienced cytotechnologists who, working independently between the cytopathology laboratory and the biopsy suite, prepare the smears and stain the slides on site for the distant cytopathologists, who can evaluate the slides remotely (usually from their office) simply using the facility intranet. This article aims to encourage big and small centres to use senior-level cytotechnologists for both ROSE and ROSE-TC. This article also defines different types of ROSE, explains our institution's approach to ROSE procedures, and outlines some experience-driven considerations for successful ROSE-TC and its future evolution.

Rapid on-site evaluation and cell blocks: getting the most from the least invasive method in cytopathology

INTRODUCTION

Fine needle aspiration cytology (FNAC) sampling is a minimally invasive procedure done to identify the pathology behind superficial and deep-seated lesions. Rapid on-site evaluation (ROSE) can be an adjunct to the FNACs. Our study aimed to identify the role of ROSE in diagnostic adequacy and to check the benefit of cell block (CB)/cell buttons prepared from the ROSE samples.

MATERIAL AND METHODS

A prospective study was conducted where all patients referred for FNAC were included. ROSE using 1% aqueous toluidine blue stain and CB/cell button preparations were done for the identification of various cytological lesions.

RESULTS

Among 600 cases included in the study most common age group was third and fourth decades with a mean age of 41.6 years and M: F ratio of 1:1.7. Ultrasound-guided procedures were done in 20% of cases. CB preparation was available in 14% of cases. Most CBs were from the cases wherein ROSE was performed 81% (77 out of 86), with CB helping in making an accurate diagnosis in 17% of cases. Lymph nodes 26%, and thyroid 23% were the most common sites for sampling with the highest number of repeat procedures from non-ROSE cases (14%). The non-diagnostic rate for non-ROSE cases was 7.7% (23/300) even after the repeat procedures as compared to 1.3% (4/300) for ROSE. Three slides on average were consumed in ROSE-performed procedures, as compared to an average of 5 slides in non-ROSE. The average turnaround time was 1.7 days for non-ROSE cases and 1.05 for ROSE cases respectively. Cyto-histopathological correlation was available in 40% of cases with a sensitivity of 98.1%, specificity of 96.7%, positive predictive value of 90%, negative predictive value of 99.4%, and diagnostic accuracy of 97%. The correlation of CB, number of slides consumed, and turnaround time among the 2 groups were statistically significant (P value < 0.001).

CONCLUSIONS

ROSE is a method used to assess material aspirated at the time of FNAC procedures to determine the adequacy and to an extent to identify whether the lesion is neoplastic or non-neoplastic. CBs have helped in increasing diagnostic accuracy apart from the fact that the paraffin-embedded tissue material can be used for further studies.

Benchmarking cytology support for ROSE during endoscopic and bronchoscopic procedures

INTRODUCTION

There has been an increase in endoscopic and bronchoscopic biopsies as minimally invasive methods to obtain specimens from gastrointestinal (GI) or pancreatobiliary lesions and thoracic or mediastinal lesions, respectively. As hospitals undertake more of these procedures, it is important to consider the staffing implications that this has on cytopathology laboratories with respect to support for rapid on-site evaluation (ROSE).

MATERIALS AND METHODS

Volume and time data from endoscopic ultrasound and bronchoscopic procedures (including endobronchial ultrasound-guided transbronchial needle aspirations and small biopsies with touch preparation) in the GI suite, bronchoscopy suite, or operating room were reviewed for 2 months at 2 different medical centers with ROSE services provided by cytologists or fellows physically present at the procedure and cytopathologists located remotely using telecytology. Statistical analysis was performed to investigate significant trends based on the location of the biopsies and other factors.

RESULTS

A total of 16 proceduralists performed 159 procedures and submitted 276 different specimens during 16 total weeks at 2 institutions. The total ROSE time for the on-site personnel to cover these procedures was 109.3 hours (bronchoscopy, 62.3 hours [57%]; GI, 29.8 hours [27%]; OR, 17.2 hours [16%]), which represents an average of 0.69 hour (41.4 minutes) per procedure or 0.40 hour (24.0 minutes) per part, with the shortest procedure times per sample recorded during bronchoscopy. When stratified by practice volume for individual proceduralists, the average time per specimen sample submitted was shorter for proceduralists with high volume practices and was most pronounced during bronchoscopy procedures.

CONCLUSIONS

Endoscopic and bronchoscopic procedures account for an increasing amount of the ROSE time for the cytology team. On average, each ROSE procedure takes 0.69 hour (41.4 minutes) or approximately 0.40 hour (24.0 minutes) per specimen, with shorter time requirements for specimens obtained in bronchoscopy procedures and for operators with high volume practices for endobronchial ultrasound-guided transbronchial needle aspirations. This provides important benchmarking data to calculate staffing needs for cytology to provide ROSE support for different proceduralists.

The use of telecytology for the evaluation of thyroid nodules fine-needle aspiration biopsy specimens: a systematic review

PURPOSE

Fine needle aspiration biopsy (FNAB) is currently the gold standard for diagnosis and treatment of thyroid nodules, but the growing need for anatomic pathology services in small communities is becoming a challenge. Telecytology (TC) is defined as the electronic transmission of cytological digital images, and allows for the collection of samples, primary diagnosis, and other applications without the physical presence of a pathologist. Our aim is to systematically report, summarize, and critically analyze the most up to date applications of TC to thyroid nodules FNAB evaluation.

METHODS

We performed a systematic literature review by searching PubMed, Embase, and Cochrane Library databases. Only studies published in peer-reviewed scientific journals were included. Data were extracted using the PICO framework and critically analyzed. PRISMA guidelines were applied, and the risk of bias in the included studies was assessed using the ROBINS-I tools. The methodological quality was assessed following GRADE criteria.

RESULTS

We included 13 observational studies, resulting in a total of 3856 evaluated FNAB specimens. The majority of studies (63.6%) showed an excellent concordance rate of diagnosis via TC and conventional cytology. TC can be used to perform preliminary assessment of samples with a concordance rate ranging from 74 and 100%, showing a significant reduction of the non-diagnostic rate. Image quality was referred to as perfect or nearly perfect in most cases, regardless of telecytology technique.

CONCLUSION

Telecytology could be a valuable implementation for thyroid FNAB evaluation both for primary diagnosis and preliminary assessment of samples.

American Society of Cytopathology Telecytology validation recommendations for rapid on-site evaluation (ROSE)

Telecytology has multiple applications, including rapid onsite evaluation (ROSE) of fine-needle aspiration (FNA) specimens. It can enhance cytopathology practice by increasing productivity, reducing costs, and providing subspecialty expertise in areas with limited access to a cytopathologist. However, there are currently no specific validation guidelines to ensure safe practice and compliance with regulations. This initiative, promoted by the American Society of Cytopathology (ASC), intends to propose recommendations for telecytology implementation. These recommendations propose that the validation process should include testing of all hardware and software, both separately and as a whole; training of all individuals who will participate in telecytology with regular competency evaluations; a structured approach using retrospective slides with defined diagnoses for validation and prospective cases for verification and quality assurance. Telecytology processes must be integrated into the laboratory's quality management system and benchmarks for discrepancy rates between preliminary and final diagnoses should be established and monitored. Special attention should be paid to minimize discrepancies that downgrade malignant cases to benign (false positive on telecytology). Currently, billing and reimbursement codes for telecytology are not yet available. Once, they are, recommendation of the appropriate usage of these codes would be a part of the recommendations. These proposed guidelines are intended to be a resource for laboratories that are considering implementing telecytology. These recommendations can help to ensure the safe and effective use of telecytology and maximize its benefits for patients.

Rapid Remote Online Evaluation in Endoscopic Diagnostics: An Analysis of Biopsy-Proven Respiratory Cytopathology

BACKGROUND

This prospective study assesses the use of rapid remote online cytological evaluation for diagnosing endoscopical achieved biopsies. It focuses on its effectiveness in identifying benign and malignant conditions using digital image processing.

METHODS

The study was conducted between April 2021 and September 2022 and involved analyses of 314 Rapid Remote Online Cytological Evaluations in total (154 imprint cytologies, 143 fine needle aspirations and 17 brush cytologies) performed on 239 patients at the LungenClinic Grosshansdorf. During on-site evaluation via telecytology, the time requirement was recorded and the findings were compared with the cyto-/histological and final diagnoses.

RESULTS

By means of rapid remote online evaluation, findings of 86 cytological benign, 190 malignant and 38 unclear diagnoses were recorded (Ø assessment time, 100 s; range, 11-370 s). In 27 of the 37 specimens with unclear diagnoses, the final findings were malignant tumours and only 6 were benign changes. The diagnosis of another 4 of these 37 findings remained unclear. Excluding these 37 specimens, rapid remote online evaluation achieved a sensitivity of 90.5% with a specificity of 98.5% and a correct classification rate of 92.4% with regard to the final diagnosis of all cases. As expected, an increase in the sensitivity rate for the cytological detection of malignant tumours (76.1% vs. 92.5%) was found especially in fine-needle aspirations.

CONCLUSIONS

Rapid remote online analysis allows the fast quantitative and qualitative evaluation of clinically obtained cytological specimens. With a correct classification rate of more than 93%, sampling deficiencies can be corrected promptly and diagnostic and therapeutic approaches can be derived.

Technical aspects of the use of cytopathological specimens for diagnosis and predictive testing in malignant epithelial neoplasms of the lung

Lung cancer is a leading cause of cancer mortality worldwide but recent years have seen a rapidly rising proportion of cases of advanced non-small cell carcinoma amenable to increasingly targeted therapy, initially based on the differential response to systemic treatment of tumours of squamous or glandular differentiation. In two-thirds of the cases, where patients present with advanced disease, both primary pathological diagnosis and biomarker testing is based on small biopsies and cytopathological specimens. The framework of this article is an overview of the technical aspect of each stage of the specimen pathway with emphasis on maximising potential for success when using small cytology samples. It brings together the current literature addressing pre-analytical and analytical aspects of specimen acquisition, performing rapid onsite evaluation, and undertaking diagnostic and predictive testing using immunocytochemistry and molecular platforms. The advantages and drawbacks of performing analysis on cell block and non-cell block specimen preparations is discussed.

Selective deployment of dynamic telecytology for rapid evaluation of cytology smears: assessment of workflow processes and role of cytopathology fellows as on-site operators

INTRODUCTION

The deployment of telecytology (TC) requires a substantial investment of financial and human resources. To offset the high demand for rapid on-site evaluation, we performed a limited deployment of dynamic TC and have detailed the workflow processes and the role of trainees.

MATERIALS AND METHODS

TC systems were installed in radiology suites with a high volume of cases. Validation was performed using retrospective and prospective cases. Cytotechnologists and cytopathology fellows were the operators of the instrument. TC malignant and benign diagnoses were correlated with the final sign-out diagnoses.

RESULTS

Of the 120 cases, 50 (41.6%) were fine needle aspirations and 70 (58.3%) were touch imprint smears of core biopsy specimens. The cytotechnologists were the operators for 34 cases (28.3%) and cytology fellows for 86 cases (71.6%). Adequacy concordance with the final diagnosis was 100% and 98.5% in the retrospective and prospective cases, respectively. In the prospective cases, concordance of TC with the final diagnosis of malignancy was 42 of 45 (93.3%), with 2 of 45 (4.4%) discordant and a downgrade rate of 2.7%. For the benign diagnoses, the concordance was 90%. For the malignant diagnoses, the sensitivity of TC was 97.67% (95% confidence interval [CI], 87.71 to 99.94%; specificity, 81.82%; 95% CI, 48.22% to 97.72%). The positive predictive value was 95.45% (95% CI, 85.69% to 98.66%), the negative predictive value was 90.00% (95% CI, 55.98% to 98.45%), and the accuracy was 94.44% (95% CI, 84.61% to 98.84%).

CONCLUSIONS

TC can be deployed in a limited fashion as an option for cytopathologists to offset the high demand for rapid on-site evaluations. Trainee participation in TC service is important for building confidence and honing their cytology skills.

Implementation and assessment of a telecytology quality assurance program

INTRODUCTION

The College of American Pathologists mandates that telepathology services are included in laboratory quality management programs. The aim of this study was to assess a telecytology quality assurance (QA) process that we implemented in 2015.

MATERIALS AND METHODS

Each month, a cytotechnologist randomly selected 3 telecytology fine-needle aspiration (FNA) cases from each cytopathologist on the FNA service that month. Data were recorded in a monthly worksheet and included onsite telecytology adequacy, final adequacy, concordance, onsite operator, cytopathologist, and reason for discrepancy, if present. The worksheet was reviewed monthly, discordant cases were re-examined, and feedback to cytologists was provided. For this study, worksheets from October 2015 to December 2019 were retrospectively reviewed.

RESULTS

The QA program captured 488 cases, representing 25% of total cases that utilized telecytology during the evaluation period (n = 1983). The telecytology onsite assessment was concordant with the final cytologic assessment in 84% (410 of 488) of cases. The majority of discordant cases (72 of 78, 92%) were the result of an "Inadequate" onsite telecytology assessment, but a final diagnosis was able to be rendered; 92% of these cases were attributed to diagnostic material being present in cytologic preparations not available during the onsite assessment. Nine telecytology onsite interpretation errors were identified, of which 7 were provided by cytopathologists with less than 2 years of experience.

CONCLUSIONS

Most telecytology cases with onsite assessment errors were evaluated by cytopathologists with less than 2 years of practice experience; therefore, careful monitoring of new staff should be considered when developing a telecytology QA program.

Results from the 2019 American Society of Cytopathology survey on rapid onsite evaluation (ROSE)-part 2: subjective views among the cytopathology community

INTRODUCTION

This study aims to improve understanding of the cytopathology community's perspective regarding the value of rapid onsite evaluation (ROSE) in clinical practice.

MATERIALS AND METHODS

The American Society of Cytopathology membership was surveyed in 2019 to obtain subjective data on the cytopathology community's perceptions regarding ROSE. Comments were categorized by major themes and attitudes and analyzed by respondent's role in laboratory, practice size, and practice setting (Fisher's exact and χ² tests).

RESULTS

A total of 541 responses were received from 255 cytopathologists/pathologists, 261 cytotechnologists, 19 trainees, and 6 others (as previously reported). Reasons for which cytopathology personnel provide this service aligned with their perceptions of why clinicians request ROSE. A minority of respondents, disproportionally from high volume centers, felt ROSE is unnecessary. Overall attitude regarding ROSE was generally positive. There were no significant differences in attitude regarding ROSE according to role in laboratory or practice size, but respondents from academic centers provided a significantly higher percentage of positive comments than those in private or community practice. Although survey respondents generally felt that ROSE is valuable to patient care, they also highlighted several challenges, including staffing, time commitment, and inadequate reimbursement. Implementation of telecytology was felt to potentially alleviate some of these challenges.

CONCLUSIONS

Survey results show that the cytology community views ROSE favorably, practices vary considerably, and there is a perceived need for improved reimbursement. Data from this study may be used to identify areas that warrant additional research to clarify the clinical value of ROSE.