Compensation crisis related to the onsite adequacy evaluation during FNA procedures-Urgent proactive input from cytopathology community is critical to establish appropriate reimbursement for CPT code 88172 (or its new counterpart if introduced in the future)

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.

Validation and implementation of telecytology at an academic medical center using digital cameras and Microsoft Teams software

INTRODUCTION

Rapid On-Site Evaluation of cytological samples obtained through fine needle aspiration for adequacy is a critical component of a cytology service; however, it imposes a significant time and cost burden for the practicing pathologist and the cytology service. Telecytology enables adequacy assessment by a pathologist remotely, greatly saving time. Telecytology also allows slide preparation and manipulation at the procedure site by an employee with less training requirements, liberating the cytotechnologist to screen cases and perform other laboratory duties - an important aspect to consider during times of cytotechnologist shortages. We propose a telecytology system with a simple setup of a microscope, microscope camera, laptop, and Microsoft Teams software.

MATERIALS AND METHODS

We designed a system consisting of a mobile cart, backup battery, microscope, digital camera, and a laptop computer with microscope imaging software and Microsoft Teams software for image transmission. Validation was performed by 4 pathologists making adequacy assessments on randomly selected previously signed out cases using the telecytology system.

RESULTS

Our validation of this system demonstrated a greater than 90% concurrence rate between the original adequacy call and the call made by pathologists using the telecytology system - a benchmark used by most, if not all, published validations of similar telecytology systems. In addition, the adequacy assessment concordance rate between select pathologists exceeded 90%.

CONCLUSIONS

In summary, our telecytology system provides excellent adequacy services for the clinicians and patients we serve. The Microsoft Teams software is a great tool for transmission of video microscopy. This system will be used with the goal of saving time and increasing efficiency for the cytopathology department.

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.

Value of transbronchial needle aspiration combined with a rapid on-site evaluation of cytology in the diagnosis of pulmonary lesions

Background

The diagnostic value of rapid on-site evaluation (ROSE) of cytology during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) remains controversial. The purpose of this study was to validate the value of ROSE during the EUBS-TBNA procedure in the diagnosis of pulmonary lesions (PLs).

Methods

Enrolled in this study were 260 patients with nodules, masses, cavities, or inflammatory lesions on pulmonary CT images. They were assigned to undergo EBUS-TBNA with ROSE (n = 134) or without ROSE (n = 126). The diagnostic results of ROSE during EBUS-TBNA and the final pathologic reports were analyzed and compared by utilizing SPSS21.0 software to evaluate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). In addition, we further explored whether the ROSE method during EBUS-TBNA would improve the diagnostic yield and reduce the incidence of complications.

Results

The overall diagnostic yield of EBUS-TBNA for malignant diseases in the ROSE and the non-ROSE group were 29.9 and 11.1%, respectively. The sensitivity, specificity, PPV and NPV of the ROSE method during EBUS-TBNA were 97.4, 96.9, 92.5, and 98.90%, respectively. The result of the chi-square test effectively proved that ROSE operation during EBUS-TBNA contributes to the diagnosis of malignancy compared with the non-ROSE group (χ² = 13.858, P < 0.001). The number of punctures in the ROSE group was significantly lower than that in the non-ROSE group (P < 0.001).

Conclusion

ROSE examination during EBUS-TBNA could effectively improve the diagnostic yield of malignant diseases compared with the non-ROSE group and reduce the number of intraoperative punctures, which is a clinical application worth popularizing.

Toward realization of remote controlled telecytopathology-a validation study from a large academic medical center from the southeast United States

INTRODUCTION

With increase in the number and types of biopsies requiring rapid on-site evaluation for adequacy, telecytopathology is one of the solutions.

MATERIALS AND METHODS

Using a microscope camera with MS Surface Pro, a live telecytopathology audio video feed for the adequacy of 55 study set validation cases was sent over Zoom from the satellite hospital over 10 miles away with cytopathologists at the main hospital. The study set cases included Diff-Quik-stained smears and core imprints.

RESULTS

The overall percent of positive agreement (accuracy) for adequacy during rapid on-site evaluation via telecytopathology was 96%. Core imprint percentage for positive agreement was slightly higher (96.2%), than fine-needle aspiration smears (95.8%).

CONCLUSIONS

Use of telecytopathology is the best solution for optimizing the cytopathologist's time for evaluating biopsy adequacy from distant sites.

Liquid-based rapid onsite evaluation of endobronchial ultrasound cytologies

INTRODUCTION

Rapid onsite evaluation (ROSE) generally uses smears made at the site of the procedure ("smear-based ROSE"). It requires considerable time, generally 2 individuals, technical expertise, and it can be difficult to estimate material available for ancillary studies. We developed an alternative ROSE using liquid-based cytology ThinPrep with hematoxylin and eosin (H&E) stain ("liquid-based ROSE") and assessed its advantages.

MATERIALS AND METHODS

Clinicians rinse the sample(s) into CytoRich Red and send to Pathology. A defined proportion of the needle rinse is removed for a ThinPrep stained with a rapid H&E. Adequacy and diagnosis were compared to final outcome. Total time was recorded.

RESULTS

Among 52 liquid-based ROSE readings, 28 (53.8%) were interpreted as "adequate" with final as adequate; 17 (32.7%) were interpreted as "inadequate" with final as inadequate; 7 (13.5%) were interpreted as "inadequate" with final as adequate. Of 23 readings provided with onsite diagnosis, 15 (65.2%) were interpreted as definitive positive or negative diagnoses; 6 (26%) were interpreted as nondiagnostic; and 2 (8.7%) were interpreted as atypical. All definitive diagnoses were concordant with final diagnoses. The time for liquid ROSE performance ranges from 6 to 22 minutes (mean: 13 minutes) and required only 1 individual.

CONCLUSIONS

Liquid-based ROSE allows accurate adequacy determination and diagnosis, takes about 15 minutes of cytologist time, and can be performed by just 1 person. The technique produces well-preserved and stained slides, it may allow a better estimation of the total amount of material in the specimen vial and may provide a better platform for telecytology.

Telecytology validation: is there a recipe for everybody?

INTRODUCTION

Telecytology offers a suitable solution to the cost and time efficiency questions on rapid onsite evaluation (ROSE). An increasing number of institutions are adopting new telecytology systems to meet the increasing ROSE requests, although there is no agreement on the details of how a telecytology validation study needs to be conducted. We propose a standardized approach for telecytology validation studies that could be done in a variety of practices.

MATERIALS AND METHODS

Consecutive cases from 6 months prior were chosen to reflect a case mix comparable to real life. A fellow assessed the slides at the ROSE site while 6 cytopathology faculty convened in a conference room with a television screen, and noted the adequacy, diagnostic category, and specific diagnoses. All participants were blinded to the original adequacy assessment and final diagnoses. For each case, evaluation time and the slides counts were noted.

RESULTS

Fine-needle aspiration specimens from 52 patients were included in the study. Of these, 13 cases were used in the first "test" session. The adequacy concordance rates ranged between 92.3% and 100%, with an overall concordance rate of 94.8%. The diagnostic category concordance rates ranged between 90.3% and 95.5%, with an overall concordance rate of 91.9%. The specific diagnosis concordance rates ranged between 84.6% and 92.9%, with an overall concordance rate of 88.1%.

CONCLUSIONS

Validation of telecytology requires a standardized approach just like any other new technology. In this study, we propose an efficient and accurate method for cytopathology departments of various case volumes to conduct telecytology validation studies.

The current practice of telecytology for rapid on-site evaluation (ROSE): Practical considerations and limitations

Advances in digital imaging technology and development of high-speed internet has brought a change in ROSE practice from the traditional in-person to remote evaluation. The rapid expansion of image-guided procedures to obtain tissues for diagnosis and ancillary testing has put a huge demand on cytopathologists' time to perform on-site adequacy assessment. The technology of transmitting digital slide images in real-time via the internet from procedure site that can be viewed remotely and provide preliminary diagnosis, has had a huge impact on the practice of ROSE. Telecytology (TC) has increased the efficiency of cytopathologists, by cutting down on travel time to procedure sites and eliminate the long wait time between procedures/needle passes. It also provides the cytopathologist with the flexibility of covering ROSE procedures occurring at several locations simultaneously. The options and design of TC systems are driven by clinical needs, availability of resources and case volume. A buy-in from stakeholders early in the process, infrastructure planning and information technology (IT) support are critical for the successful implementation of TC. Training of staff, validation study and compliance training should be performed according to established guidelines. There are different TC platforms commercially available in the market today, these include static image sharing, real-time video streaming, robotic microscopy and whole slide imaging (WSI). Additionally, low-cost TC system can be built and designed using equipment that are available off-the-shelf. The intent of this review is to highlight the current practices of TC, the pros and cons of each system are discussed.

Interobserver agreement between pathologist, pulmonologist and molecular pathologist to estimate the tumour burden in rapid on-site evaluation smears from endosonography and guided bronchoscopy

OBJECTIVE

A growing number of studies have suggested that non-pathologists can reliably assess the adequacy and malignancy in rapid on-site evaluation (ROSE) smears prepared during endoscopic sampling procedures. However, no study has verified whether they can also consistently estimate the tumour burden, which is critical for the molecular profiling of lung cancer. We aimed to assess the interobserver agreement (IOA) between a pathologist, a pulmonologist (previously trained in lung and lymph node cytopathology) and a molecular pathologist for the tumour burden in ROSE smears.

METHODS

The ROSE smears of consecutive patients with suspected lung cancer undergoing endosonography or guided bronchoscopy were assessed independently by a pathologist, a pulmonologist and a molecular pathologist (gold standard). The IOA for the tumour burden, assessed through k-statistics, was the primary outcome.

RESULTS

A total of 322 ROSE smears obtained from 162 patients were evaluated. The IOA between the molecular pathologist and pulmonologist was very good (moderate to substantial), although slightly inferior to the IOA between the molecular pathologist and pathologist in the whole slide set (k: 0.707, 95% confidence interval [CI]: 0.677-0.739 vs 0.793, 95% CI: 0.762-0.815), as well as in smears prepared from lymphadenopathy (k: 0.783, 95% CI: 0.760-0.855 vs 0.827, 95% CI: 0.728-0.892) or from pulmonary nodules/masses (k: 0.558, 95% CI: 0.416-0.686 vs 0.715, 95% CI: 0.621-0.767).

CONCLUSIONS

A professionally trained pulmonologist can reliably estimate the tumour burden in bronchoscopically derived ROSE smears, especially in the setting of lymphadenopathy. This can be particularly useful in institutions where a cytopathologist is not available regularly.

Rapid On-Site Cytologic Evaluation: A Feasibility Study Using Ancillary Interventional Pulmonary Personnel

BACKGROUND

Ancillary health professionals helping in a procedural service is a common practice everywhere.

OBJECTIVES

This was a proof-of-concept study to assess feasibility of using ancillary personnel for rapid on-site cytologic evaluation (ROSE) at interventional pulmonary procedures.

METHODS

After a training interval, a respiratory therapist (RT) performed ROSE on consecutive interventional pulmonary specimens. Sample sites included lymph nodes, lung, liver, and the left adrenal gland. RT findings were subsequently correlated with blinded cytopathology-performed ROSE and with final histopathology results, with primary foci of adequacy and the presence or absence of malignancy.

RESULTS

Seventy consecutive cases involved 163 separate sites for ROSE analysis. Adequacy: There was a high level of concordance between RT-performed ROSE (RT-ROSE) and cytopathology ROSE (CYTO-ROSE). They agreed upon the adequacy of 159 specimens. The Cohen's κ coefficient ± asymptotic standard error (ASE) was 0.74 ± 0.175, with p < 0.0001. Malignancy: RT-ROSE concurred highly with CYTO-ROSE, with agreement on 150 (92%) of the 163 specimens. Cohen's κ coefficient ± ASE was 0.83 ± 0.045, with p < 0.0001. When the comparison was for malignancy by case rather than individual site, Cohen's κ coefficient ± ASE was 0.68 ± 0.08, with p < 0.0001.

CONCLUSION

This study demonstrates that ancillary personnel supporting an interventional pulmonary service can be trained to perform initial ROSE. Cytopathology can be called after sampling and staining have produced adequate samples. This setup streamlines ROSE evaluation with regard to time and cost.

Review of different platforms to perform rapid onsite evaluation via telecytology

There is increased utilisation of cytopathology to provide a rapid onsite evaluation (ROSE) of fine needle aspiration and touch preparations of small biopsies. A well-executed ROSE procedure can significantly impact the diagnostic quality and appropriate specimen triage of procured biopsy materials. To accommodate the demand for ROSE, telecytology has been increasingly implemented to facilitate ROSE occurring remotely. Telecytology can be categorised based on camera systems including eyepiece system, camera port system and robotic microscope/whole slide image scanner system. Image sharing methods include static images, broadcast only live video streaming, teleconferencing and whole slide image management system. In this review, we will discuss the advantages and disadvantages of each of these systems and deployment considerations.

A Trained Pulmonologist Can Reliably Assess Endosonography-Derived Lymph Node Samples during Rapid On-Site Evaluation

BACKGROUND

The widespread use of rapid on-site evaluation is hampered by constraints related to time and resources, inadequate reimbursement, and evidence from randomized trials that show a lack of increase in diagnostic yield and specimen adequacy associated with its usage.

OBJECTIVE

We aimed to verify whether a pulmonologist can assess endosonography-derived lymph node samples after a comprehensive and reproducible training provided by a specialist pathologist.

METHODS

Prospective, observational trial structured in three phases. In the first (training) phase, a pathologist critically evaluated the smears from 150 archival endosonography cases with a pulmonologist. In the second (test) phase, the pulmonologist was asked to assess 50 archival endosonography-derived samples. In the last (real-life) phase, the pulmonologist classified the samples from 200 patients during the endosonography. The overall agreement between pulmonologist and pathologist (gold standard), assessed through κ-statistics, was the primary outcome. The agreement for the identification of specific cytological categories was the secondary outcome.

RESULTS

The overallagreement between pulmonologist and pathologist was 84% (κ0.765, 95% CI 0.732-0.826) in the test phase and 89.7% (κ 0.844, 95% CI 0.799-0.881) in the real-life phase. The agreement for specific cytological categories was 92.7% (95% CI 0.824-0.980) for inadequate samples, 90.3% (95% CI 84.5-94.5%) for reactive lymphadenopathies, 90.5% (95% CI 0.845-0.946) for malignancy, and 73% (95% CI 0.515-0.897) for granulomatous samples.

CONCLUSIONS

A trained pulmonologist can reliably assess adequacy and malignancy for endosonography-derived samples, which could be useful in institutions where a cytopathologist/cytotechnician is not available regularly.

Rapid on-site evaluation using telecytology: A major cancer center experience

BACKGROUND

Rapid on-site evaluation (ROSE) with cytology preparations plays a critical role in minimally invasive procedures. The time spent by a pathologist performing ROSE is unpredictable and could be used for more cost-effective activities. The solution encountered by several institutions to address this issue is the use of telecytology (TC). This study analyzes the experience of using telecytology for ROSE in a major cancer center over a period of over 2 years.

METHODS

A retrospective analysis of all remote TC evaluations for adequacy on fine needle aspiration (FNA) and touch preparations (TP) of core biopsies (CB) performed at a major cancer center was performed. The preliminary adequacy assessment was then compared to the adequacy assessment at final diagnosis.

RESULTS

A total of 12 949 adequacy assessments were analyzed. The most common sites biopsied in our institution were lymph node, lung, and liver. There were 7725 adequacy assessments for CB (59.7%), while adequacy assessment for FNA specimens represented 40.3% (n = 5224) of the total number of specimens evaluated by ROSE. Perfect concordance between initial adequacy assessment and the adequacy assessment at final cytologic diagnosis was 93% (12 049/12 949). The final diagnosis adequacy upgrade rate was 6.7% (n = 863), and the adequacy downgrade (a specimen considered adequate on-site that was determined to be nondiagnostic on final examination) was 0.3% (n = 37).

CONCLUSIONS

TC can be easily implemented with the current technologies available. It is cost-effective and allows for better patient care with a more efficient use of the pathologist's time and laboratory resources.

Rapid on-site pathologic evaluation does not increase the efficacy of endobronchial ultrasonographic biopsy for mediastinal staging

BACKGROUND

Endobronchial ultrasonography with transbronchial needle aspiration (EBUS-TBNA) has been shown to be equivalent to mediastinoscopy in lung cancer staging for mediastinal node involvement. Rapid on-site evaluation (ROSE) to determine the adequacy of nodal sampling has been claimed to be beneficial.

METHODS

A retrospective evaluation was performed in 170 patients who underwent EBUS-TBNA from July 2008 to May 2011. The patients were classified as having either high or low pretest probability for mediastinal disease based on history and radiographic imaging. ROSE was compared with the final pathology reports based on slides and cell blocks.

RESULTS

One hundred thirty-one (77%) patients were classified as being in the high pretest cohort based on clinical staging. Of these, 101 (77%) patients had adequate tissue sampling based on ROSE, with 70 (69%) patients having positive mediastinal disease. In the 30 (23%) patients who had inadequate tissue by ROSE, the final analysis of all the prepared slides and cell blocks allowed for a diagnosis in all but 8 patients. The sensitivity and specificity of ROSE in the high pretest probability cohort were 89.5% and 96.4%, respectively, whereas the overall sensitivity and specificity of EBUS-TBNA was 92.1% and 100%, respectively. Despite having inadequate tissue on ROSE in 30 of 131 patients, sufficient tissue was available on final analysis for diagnosis in 22 of 30 patients.

CONCLUSIONS

ROSE does not impact clinical decision making if a thorough mediastinal staging using EBUS is performed. Despite inadequate tissue sampling assessment by ROSE, a final diagnosis was made in most patients, potentially avoiding an additional surgical procedure to prove mediastinal disease.

Cytotechnologist-attended on-site adequacy evaluation of thyroid fine-needle aspiration: comparison with cytopathologists and correlation with the final interpretation

Recent increases in the number of thyroid fine-needle aspiration (FNAs) biopsies and the popularity of on-site evaluation for adequacy (OSEA) have led many practices, including ours, to rely on cytotechnologists for performing OSEA. We retrospectively analyzed the accuracy of a cytotechnologist against that of a cytopathologist in performing OSEA and making the final diagnosis. Of 2,261 thyroid FNA specimens evaluated over a 33-month period under ultrasound guidance with OSEA, the cytotechnologist attended 64.7% (1,462/2,261) of the procedures whereas the cytopathologist attended 35.3% (799/2,261). There was no difference in the adequacy downgrade rate for cytotechnologists compared with that for cytopathologists during this study period (4.1% vs 5.0% downgrade rate, P = .33). Regardless of who rendered the OSEA, subadequate specimens had a higher rate of indeterminate diagnosis (25.2%) than those specimens deemed adequate at the time of OSEA (11.9%, P = .00001). These results indicate that the accuracy of cytotechnologists is comparable with that of cytopathologists in conducting OSEA of the thyroid.

Utility of on-site evaluation of endobronchial ultrasound-guided transbronchial needle aspiration specimens

Background:

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an integral tool in the diagnosis and staging of malignant tumors of the lung. Rapid on-site evaluation (ROSE) of fine needle aspiration (FNA) samples has been advocated for as a guide for assessing the accuracy and adequacy of biopsy samples. Although ROSE has proven useful for numerous sites and procedures, few studies have specifically investigated its utility in the assessment of EBUS-TBNA specimens. The intention of this study was to explore the utility of ROSE for EBUS-TBNA specimens.

Materials and Methods:

The pathology files at our institution were searched for all EBUS-TBNA cases performed between January 2010 and June 2010. The data points included number of sites sampled per patient, location of site(s) sampled, on-site evaluation performed, preliminary on-site diagnosis rendered, final cytologic diagnosis, surgical pathology follow-up, cell blocks, and ancillary studies performed.

Results:

A total of 294 EBUS-TBNA specimens were reviewed and included in the study; 264 of 294 (90%) were lymph nodes and 30 of 294 (10%) were lung mass lesions. ROSE was performed for 140 of 294 (48%) specimens. The on-site and final diagnoses were concordant in 104 (74%) and discordant in 36 (26%) cases. Diagnostic specimens were obtained in 132 of 140 (94%) cases with on-site evaluation and 138 of 154 (90%) without on-site evaluation. The final cytologic diagnosis was malignant in 60 of 132 (45%) cases with ROSE and 46 of 138 (33%) cases without ROSE, and the final diagnosis was benign in 57 of 132 (47%) with ROSE and 82 of 138 (59%) without ROSE. A cell block was obtained in 129 of 140 (92%) cases with ROSE and 136 of 154 (88%) cases without ROSE.

Conclusions:

The data demonstrate no remarkable difference in diagnostic yield, the number of sites sampled per patient, or clinical decision making between specimens collected via EBUS-TBNA with or without ROSE. As a result, this study challenges the notion that ROSE is beneficial for the evaluation of EBUS-TBNA specimens.