Rapid on-site evaluation with dynamic telecytopathology for ultrasound-guided fine-needle aspiration of head and neck nonthyroid lesions

Telecytology - remote rapid on-site evaluation for ultrasound-guided head and neck fine needle aspiration utilising a clinical imaging assistant with an extended practice role

OBJECTIVE

Rapid On-Site Evaluation (ROSE) of fine needle aspirations (FNA) is widely accepted as best practice, resulting in better outcomes and delivery of care for patients. However, it is not always practical for cytology laboratories to release staff. To increase the availability of ROSE, this study aimed to robustly test the effectiveness of Telecytology ROSE (TCROSE) utilising a clinical imaging assistant (CIA) to prepare the samples and operate the microscope.

METHODS

The study was divided into 3 phases. Phase 1, equipment testing, validation and in-house training for the CIA and the Consultant Biomedical Scientist (CBMS) performing TCROSE. Phase 2, Verifying TCROSE on the same site as the cytology laboratory and phase 3, TCROSE utilising a clinic at a peripheral site away from the cytology laboratory.

RESULTS

78/80 (97% sensitivity, 95% accuracy) of TCROSE cases matched the final report for assessment of adequacy and sufficient sampling, demonstrating 94% reliability with a 95% confidence value. An appropriately trained CIA effectively prepared the samples and operated the microscope for remote interpretation. The samples were triaged effectively, and biopsy requests were appropriate to reduce the need for repeat procedures and delays in treatment. This approach received positive feedback from patients.

CONCLUSION

TCROSE utilising a CIA provides a highly effective alternative to conventional ROSE, minimising the resources required from cytopathology services and improving patient care and access to best practice. This study supports the validity of trained CIAs for a more involved role in the ultrasound-guided FNA service.

Polyphyllin D induces necroptosis in neuroblastoma cells (IMR-32 and LA-N-2) in mice

BACKGROUND

We previously reported that polyphyllin D, the main component of the traditional herbal medicinal Paris polyphylla, exhibited anticancer effects in vitro against human neuroblastoma cells. The aim of this investigation was to examine in vivo antitumor effects of polyphyllin D.

METHODS

Subcutaneous tumors were established in immune-deficient BALB/c nude mice using human neuroblastoma cell lines IMR-32 and LA-N-2. To evaluate the polyphyllin D activity, we used a mouse model of IMR-32 or LA-N-2 cell lines and analyzed subcutaneous tumors.

RESULTS

Subcutaneous tumor models were successfully established in mice using two human neuroblastoma cell lines. In the subcutaneous tumor model, porphyrin D was found to suppress tumor volume. We found that polyphyllin D suppressed the number of foci by Ki-67 staining (IMR-32 and LA-N-2; p < 0.01, 0.02, respectively). We found that polyphyllin D induces the RIPK3 expression, while polyphyllin D phosphorylates Ser358 in IMR-32 and Ser358 and Tyr376 in LA-N-2.

CONCLUSION

We developed a mouse model of subcutaneous tumors of neuroblastoma and demonstrated for the first time that polyphyllin D has an antitumor effect on neuroblastoma. Polyphyllin D can cause necroptosis depending on the cell type. The new drug can be expected by investigating a method to selectively induce cell death through the analysis of necroptosis.

Histology-based and cytology-based needle sampling for targeted next-generation sequencing in the indeterminate thyroid tumors

PURPOSE

To establish the optimal and minimally invasive diagnostic approach for targeted next-generation sequencing (NGS) in the indeterminate thyroid tumors.

METHODS

The patients with indeterminate thyroid tumors were prospectively recruited and analyzed in a single tertiary medical center. We performed FNA and core needle biopsy (CNB) at the surgical specimens to confirm the quality of each sampling procedure. Cytological diagnosis by FNA, histological diagnosis by CNB and confirmed diagnosis by final surgery were compared to demonstrate the agreement among these approaches for the indeterminate thyroid tumors. The quality of the samples from FNA and CNB was evaluated, respectively to determine the optimal approach for targeted NGS. Finally, we performed ultrasound-guided CNB and FNA (US-CNB and US-FNA) on one case to confirm the clinical feasibility of being a pre-operative minimally invasive diagnostic approach.

RESULTS

A total of 6 female patients (average age: 50.83 ± 15.18 years) with indeterminate thyroid tumors (average size: 1.79 ± 0.91 cm) were recruited for further analyses. The pathological diagnoses could be obtained by CNB in the first five cases, and the sample quality of CNB for targeted NGS was better than that of FNA, even after 10X dilution. The gene mutations associated with thyroid malignancy could be detected by NGS. In the case treated with US-CNB, the pathological and targeted NGS results were successfully obtained, which suggested the possibility of thyroid malignancy to facilitate immediate decision of subsequent treatment.

CONCLUSION

CNB could serve as a minimally invasive diagnostic approach in the indeterminate thyroid tumors by providing pathological diagnoses and qualified samples for detection of mutated genes, which facilitates appropriate and immediate management.

Utility of the Milan system for reporting salivary gland cytopathology during rapid on-site evaluation (ROSE) of salivary gland aspirates

OBJECTIVE

Rapid on-site evaluation (ROSE) is a fine needle aspiration (FNA) technique for ensuring sampling adequacy and triaging samples. The Milan system for reporting salivary gland cytopathology (MSRSGC) is a standardised reporting system which aims to improve risk stratification. There is scant literature on the diagnostic value and agreement of MSRSGC on ROSE with final cytological diagnosis in salivary gland FNAs. We aimed to assess the concordance of MSRSCG categorisation and diagnosis on ROSE with final cytological and histological diagnosis.

METHODS

This prospective study included consecutive salivary gland FNAs for which ROSE was performed over a six-month period. MSRSGC category and diagnosis on ROSE were compared with the final cytological diagnosis and MSRSGC category, and histopathological diagnosis, where available.

RESULTS

Sixty salivary gland aspirates were included. The adequacy rate with ROSE was 100%. Using the MSRSGC classification during ROSE, 26 (43.2%) samples were categorised as benign neoplasm, 21 (35%) as malignant neoplasm, 9 (15%) as non-neoplastic, and one each (1.7%) belonged to the remaining four categories. MSRSGC categorisation on ROSE concurred with final the cytological diagnosis in 58/60 cases (96.7%). Discrepancies in MSRSGC categories on ROSE included one atypia of undetermined significance with final report as non-neoplastic, and one non-diagnostic as suspicious for malignancy. Good correlation of MSRSGC categories on ROSE with final histopathological diagnosis (88.9% concordance) was also noted.

CONCLUSIONS

MSRSGC on ROSE shows good concordance with final cytology and histopathology diagnosis, indicating that categorisation according to MSRSGC has utility in ensuring that adequate material is obtained and triaged appropriately for the diagnosis of salivary gland aspirates.

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.

Utilization of Dynamic Telecytopathology for Rapid Onsite Evaluation of Touch Imprint Cytology of Needle Core Biopsy: Diagnostic Accuracy and Pitfalls

Background: In the era of personalized medicine, there has been an increase in demand on cytopathology service to perform rapid onsite evaluation of touch imprints (ROSETIs) of needle core biopsies (NCBs) to ensure sample adequacy and provide preliminary diagnosis. Limited publications have addressed use of telecytopathology for ROSETIs. We present our experience with telecytopathology-guided ROSETIs of NCBs. Materials and Methods: Cytotechnologist onsite transmitted real-time images of Diff-QUIK stained touch imprints of NCBs using an Olympus digital camera through Ethernet to a pathologist. The preliminary diagnosis from telecytopathology-guided ROSETIs was compared with that of the final NCB for diagnostic accuracy. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Results: Of 186 cases, 163 (87%) were concordant and 23 (13%) were discordant. Of the 23 discordant cases, 14 (58%) were diagnosed as benign with final NCB diagnoses as malignant and 9 (41%) were suspicious on ROSETIs with final NCB diagnoses as benign. The causes of discordance among cases categorized as benign on preliminary and malignant on final included interpretative error (9) and sampling (6). Six cases categorized as suspicious on preliminary and negative on final biopsy diagnosis correlated with concurrent fine-needle aspiration, raising the possibility of loss of diagnostic areas in processed tissue cores. Remaining three cases in this category represented misinterpretation of reactive cells. Sensitivity, specificity, PPV, and NPV were 87.9%, 95.7%, 97.1%, and 82.7%, respectively. Conclusions: Telecytopathology-guided ROSETI yields high accuracy for preliminary interpretation of NCBs and may be utilized as an effective substitute for conventional microscopy.

Dynamic Telecytopathology-Guided Rapid On-Site Assessment of Percutaneous Image-Guided Fine-Needle Aspiration of Hepatic Lesions: An Institutional Review of 178 Cases

Background: Rapid on-site evaluation (ROSE) of image-guided fine-needle aspiration (IGFNA) of hepatic lesions is necessary to ensure adequate sample collection and render preliminary diagnosis. We review our experience with utilization of telecytopathology for ROSE of IGFNA of liver lesions. Materials and Methods: Cytotechnologists at a remote site transmitted real-time images of Diff-Quik-stained cytology smears of hepatic lesions obtained using an Olympus DP70 digital camera via Ethernet to a pathologist. All live communications were conducted using the Vocera voice communication system. Preliminary telecytopathology ROSE diagnosis was compared with the final diagnosis for accuracy. Results: ROSE using telecytopathology of IGFNAs of hepatic lesion was performed on a total of 178 cases. Preliminary diagnosis of unsatisfactory, benign, suspicious for malignancy, and positive for malignancy was 2%, 28%, 15%, and 55%, respectively, for telecytopathology. The overall concordance between the preliminary and final cytology diagnoses was 94.4%. Nine of the cases were upgraded to suspicious/malignant final diagnosis contributing to an upgrade rate of 5%. One case with preliminary evaluation of positive for malignancy was downgraded to benign cytology on final diagnosis resulting in a downgrade rate of 0.1%. Conclusion: Utilization of telecytopathology is highly effective and accurate for ROSE of IGFNAs of hepatic lesions and may serve as a substitute for conventional microscopy.

This 'Rose' Has no Thorns-Diagnostic Utility of 'Rapid On-Site Evaluation' (ROSE) in Fine Needle Aspiration Cytology

Fine needle aspiration (FNA) cytology is a basic diagnostic technique used to investigate superficial and deep swellings. Rapid on-site evaluation (ROSE) using toluidine blue (TB) is easily available, cheap, cost-effective, can be used both for testing adequacy and giving provisional diagnosis. To evaluate the role of ROSE using toluidine blue staining in arriving at a diagnosis in comparison to routine stains. A total of 1500 cases of FNA of palpable swellings from sites like salivary gland, breast, thyroid, lymph node, and soft tissue lesions [non-image guided] during a 9-month period were studied. All the cases were evaluated by ROSE using toluidine blue stain and routine Giemsa/PAP staining. The results were compared in each case. Only 2% cases proved inadequate on TB, Giemsa and PAP combination, commonest site of inadequacy being lymph node. Adequate sample was obtained within two passes in 92.5% cases. The turn-around time (TAT) was 1 day in 96.4% of cases. The average time for making a provisional diagnosis on TB was 3 minutes. There was 99.2% concordance between TB and final cyto-diagnosis. Validity parameters: sensitivity 98%, specificity 100%, positive predictive value 100%, negative predictive value 99.8%, efficacy 99.2% and false negative 1.94%. ROSE using toluidine blue is a reliable means of demonstrating sample adequacy, for making a provisional diagnosis and guiding collection of diagnostic material for microbiology, immunocytochemistry (ICC), cell block and molecular testing etc. The technique is easy enough for general laboratories to incorporate into their routine practice. ROSE can be called as the "frozen section of cytology".

Efficacy of telecytopathology for preliminary assessment of fine-needle aspirations performed at a remote facility

INTRODUCTION

The need for real time anatomic pathology services has grown as healthcare systems, traditionally found at large medical centers, expand into smaller communities. The placement of a pathologist is not cost-, time-, or resource-efficient. Telecytopathology can provide rapid offsite evaluation of cytology tissues. This study evaluated the accuracy rate of rendered preliminary assessments for telecytopathology of ultrasound (US)-guided fine-needle aspirations (FNAs) for an offsite facility by comparing preliminary assessment results with the final diagnosis.

MATERIALS AND METHODS

The pathology database was searched for telecytopathology US-guided FNAs with rapid offsite evaluation performed at a regional care center from August 2014 to June 2016. A total of 674 consecutive US-guided FNAs from 444 patients were obtained. FNA sites included lymph node (345 cases), breast (178 cases), thyroid gland (71 cases), and others (80 cases).

RESULTS

Preliminary assessments of the 674 FNAs were adequate/benign in 275 (41%) cases, adequate/malignant in 182 (27%) cases, adequate/further review needed in 162 (24%) cases, indeterminate/borderline cellularity in 37 (5%) cases, and nondiagnostic in 18 (3%) cases. Final FNA diagnoses rendered included 391 (58%) negative for malignancy, 205 (30%) malignant, 34 (5%) atypical/suspicious for malignancy, 26 (4%) indeterminate cellularity-favor benign, and 18 (3%) nondiagnostic specimens. Concurrent core biopsy was performed in 42 cases and 83 cases were triaged for ancillary studies. The majority (99%) of US-guided FNAs demonstrated concordant preliminary assessments with the final diagnoses. A major discrepancy occurred in 1 case; 5 cases had minor discrepancies.

CONCLUSIONS

Remote facility telecytopathology can be utilized as an accurate modality in guiding appropriate tissue acquisition and final diagnosis.

Use of a Hands Free, Instantaneous, Closed-Loop Communication Device Improves Perception of Communication and Workflow Integration in an Academic Teaching Hospital: A Pilot Study

Efficient and effective communication between providers is critical to quality patient care within a hospital system. Hands free communication devices (HFCD) allow instantaneous, closed-loop communication between physicians and other members of a multidisciplinary team, providing a communication advantage over traditional pager systems. HFCD have been shown to decrease emergency room interruptions, improve nursing communication, improve speed of information flow, and eliminate health care waste. We evaluated the integration of an HFCD with an existing alphanumeric paging system on an acute inpatient medicine service. We conducted a prospective, observational, survey-based study over twenty-four weeks in an academic tertiary care center with attending physicians and residents. Our intervention involved the implementation of an HFCD alongside the existing paging system. Fifty-six pre and post surveys evaluated the perception of improvement in communication and the integration of the HFCD into existing workflow. We saw significant improvements in the ability of an HFCD to help physicians communicate thoughts clearly, communicate thoughts effectively, reach team members, reach ancillary staff, and stay informed about patients. Physicians also reported better workflow integration during admissions, rounds, discharge, and teaching sessions. Qualitative data from post surveys demonstrated that the greatest strengths of the HFCD included the ability to reach colleagues and staff quickly, provide instant access to individuals of the care team, and improve overall communication. Integration of an instantaneous, hands free, closed loop communication system alongside the existing pager system can provide improvements in the perceptions of communication and workflow integration in an academic medicine service. Future studies are needed to correlate these subjective findings with objective measures of quality and safety.

Integrated Pathology Informatics Enables High-Quality Personalized and Precision Medicine: Digital Pathology and Beyond

CONTEXT

- The critical role of pathology in diagnosis, prognosis, and prediction demands high-quality subspecialty diagnostics that integrates information from multiple laboratories.

OBJECTIVE

- To identify key requirements and to establish a systematic approach to providing high-quality pathology in a health care system that is responsible for services across a large geographic area.

DESIGN

- This report focuses on the development of a multisite pathology informatics platform to support high-quality surgical pathology and hematopathology using a sophisticated laboratory information system and whole slide imaging for histology and immunohistochemistry, integrated with ancillary tools, including electron microscopy, flow cytometry, cytogenetics, and molecular diagnostics.

RESULTS

- These tools enable patients in numerous geographic locations access to a model of subspecialty pathology that allows reporting of every specimen by the right pathologist at the right time. The use of whole slide imaging for multidisciplinary case conferences enables better communication among members of patient care teams. The system encourages data collection using a discrete data synoptic reporting module, has implemented documentation of quality assurance activities, and allows workload measurement, providing examples of additional benefits that can be gained by this electronic approach to pathology.

CONCLUSION

- This approach builds the foundation for accurate big data collection and high-quality personalized and precision medicine.

Clinical Applications of Whole-slide Imaging in Anatomic Pathology

The development of whole-slide imaging has paved the way for digitizing of glass slides that are the basis for surgical pathology. This transformative technology has changed the landscape in research applications and education but despite its tremendous potential, its adoption for clinical use has been slow. We review the various niche applications that initiated awareness of this technology, provide examples of clinical use cases, and discuss the requirements and challenges for full adoption in clinical diagnosis. The opportunities for applications of image analysis tools in a workflow will be changed by integration of whole-slide imaging into routine diagnosis.

Application of Ultrasound-Guided Core Biopsy to Minimal-Invasively Diagnose Supraclavicular Fossa Tumors and Minimize the Requirement of Invasive Diagnostic Surgery

Tumors of the supraclavicular fossa (SC) is clinically challenging because of anatomical complexity and tumor pathological diversity. Because of varied diseases entities and treatment choices of SC tumors, making the accurate decision among numerous differential diagnoses is imperative. Sampling by open biopsy (OB) remains the standard procedure for pathological confirmation. However, complicated anatomical structures of SC always render surgical intervention difficult to perform. Ultrasound-guided core biopsy (USCB) is a minimally invasive and office-based procedure for tissue sampling widely applied in many diseases of head and neck. This study aims to evaluate the clinical efficacy and utility of using USCB as the sampling method of SC tumors. From 2009 to 2014, consecutive patients who presented clinical symptoms and signs of supraclavicular tumors and were scheduled to receive sampling procedures for diagnostic confirmation were recruited. The patients received USCB or OB respectively in the initial tissue sampling. The accurate diagnostic rate based on pathological results was 90.2% for USCB, and 93.6% for OB. No significant difference was noted between USCB and OB groups in terms of diagnostic accuracy and the percentage of inadequate specimens. All cases in the USCB group had the sampling procedure completed within 10  minutes, but not in the OB group. No scars larger than 1  cm were found in USCB. Only patients in the OB groups had the need to receive general anesthesia and hospitalization and had scars postoperatively. Accordingly, USCB can serve as the first-line sampling tool for SC tumors with high diagnostic accuracy, minimal invasiveness, and low medical cost.