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.

Changing digital and telecytology practices post COVID-19 comparing ASC survey results from 2016 to 2023

INTRODUCTION

During the COVID-19 pandemic, the need for digital pathology tools became more urgent. However, there needs to be more knowledge of the use in cytology. We aimed to evaluate current digital cytology practices and attitudes and compare the results with a pre-COVID-19 American Society of Cytopathology (ASC) survey.

MATERIALS AND METHODS

Fourteen survey questions assessing current attitudes toward digital cytology were developed from a 2016 ASC Digital Pathology Survey. Ten new survey questions were also created to evaluate telecytology use. The survey was e-mailed to ASC members over 6 weeks in 2023.

RESULTS

A total of 123 individuals responded (116 in 2016). Attitudes toward digital cytology were unchanged; most participants stated digital cytology is beneficial (87% 2023 versus 90% 2016). The percentage of individuals using digital cytology was unchanged (56% in 2016 and 2023). However, telecytology for rapid onsite assessment (ROSE) is now considered the best application (55% 2023 versus 31% 2016). Forty-three institutions reported using digital and telecytology tools; 40% made implementations after 2020; most did not feel that COVID-19 affected digital cytology (56%). Telecytology for ROSE is the most common application now (78%) compared with education (30%) in 2016. Limitations for implementing digital imaging in cytology included inability to focus (38%) and expense (33%).

CONCLUSIONS

General attitudes toward digital tools by the cytology community have essentially remained the same between 2016 and now. However, telecytology for ROSE is increasingly being used, which supports a need for validation and competency guidelines.

Telecytology rapid onsite evaluation, with real-time communication between cytopathologist, cytotechnologist, and proceduralist, offers better adequacy rates for lymph node, but not thyroid, fine-needle aspirations

INTRODUCTION

Rapid onsite evaluation (ROSE) decreases rates of inadequate fine-needle aspirations (FNAs). Telecytology allows pathologists to perform ROSE without being physically "on site", thereby saving cytopathologists' travel time and allowing them to perform ROSE for multiple institutions. Little research exists comparing telecytology to non-telecytology ROSE for FNA inadequacy rates.

MATERIALS AND METHODS

Using previously obtained quality metrics, we compared inadequacy rates for lymph node and thyroid FNAs with and without ROSE and with non-telecytology ROSE compared with telecytology ROSE. Use of ROSE was determined by the proceduralist. Type of ROSE was location-based, as only certain locations at our institution have telecytology capabilities. Chi-squared testing was used to compare proportions of populations and P value was set to 0.05.

RESULTS

A total of 1168 lymph node and 1177 thyroid FNAs were included in our adequacy analysis. We found any ROSE decreased our inadequacy rate for both lymph node (20.4% to 12.7%, P = 0.002) and thyroid (34.7% to 4.8%, P = 7.4 × 10-18) FNAs. We found telecytology further decreased our inadequacy rate for lymph node (13.8% to 5.9%, P = 0.016), but not thyroid (3.3% to 5.0%, P = 0.34), FNAs.

CONCLUSIONS

At our institution, when using telecytology, slides are read in real time with the cytotechnologist and the proceduralist looking at slides together near the patient bedside, while the cytopathologist is on the phone looking at slides on the computer screen via Dameware. When non-telecytology ROSE is performed, the cytotechnologist evaluates a slide, brings it to the cytopathologist's office and then the cytopathologist calls the proceduralist to discuss the slide. We believe telecytology offers an opportunity for more inclusive communication thereby improving adequacy rates for more complex cases, like lymph nodes, without affecting adequacy rates for cases where assessment of adequacy is less complex, like thyroid. This research supports use of telecytology especially for complex cases.

Integrating cytology into routine digital pathology workflow: a 5-year journey

Despite recent advances in digital imaging, the adoption of digital cytology is challenging due to technical limitations. This study describes our 5-year institutional experience with the implementation of digital cytology. The routine cytology workflow included conventional two-step screening by cytotechnologists, followed by sign out by pathologists. We introduced sign out of cytologic cases using a microscopic digital imaging platform operated by cytotechnologists, which allowed for remote review of slides by cytopathologists via video streaming. We also provided cytologic correlation to support the virtual slide-based sign out of histopathological specimens and for a weekly pathology-radiology conference. In addition, positive cytology cases were archived for integration into the laboratory information system and for prospective computational pathology studies. We also summarized lessons learned over the years and outlined our vision for future developments. This unique experience may serve as a role model for other institutions.

Digital Cytology in Exotic Practice: Tips to Optimize Diagnosis

Digitization has enhanced the utility of cytology in private practice by allowing for rapid sample receipt and analysis, leading to better informed real-time patient care. Despite many advantages of digital cytology, understanding its limitations is required to avoid common pitfalls. A strong foundation in sample preparation and imaging techniques is also required to obtain high-quality diagnostic samples. By optimizing these factors, the benefits of digital cytology are maximized, allowing for the practice of high-quality point-of-care medicine that best addresses the needs of the patient and pet owner in a rapid time frame.

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.

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.

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.

Remote cytological diagnosis of salivary gland lesions by means of precaptured videos

OBJECTIVE

The objective of this study was to investigate the feasibility of implementing videos captured by static telecytological applications for remote cytological diagnosis of fine needle aspiration (FNA) specimens from salivary gland lesions.

METHODS

The current study was performed on 102 specimens from patients referred to the Alpha Prolipsis Cytopathology Department for preoperative evaluation of salivary gland lesions. In all cases, surgical excision followed the initial cytological diagnosis. (benign lesions, 11; benign neoplasms, 68; malignant neoplasms, 23). Videos were transferred via file transfer protocol to password-protected accounts for remote review by three independent cytopathologists. In addition to diagnosis, reviewers commented on overall digital video quality. Contributor's and reviewer's diagnoses were collected, recorded and statistically evaluated.

RESULTS

Statistical evaluation of cytological diagnoses detected no significant difference in diagnostic accuracy between the diagnoses proffered on the basis of precaptured videos and conventional slides. The overall interobserver agreement was ranging from substantial to almost perfect with κ values of 0.71-0.89.

CONCLUSIONS

Videos production by static telecytology applications can be used as an alternative method for telecytological diagnosis of salivary glands FNAs. Videos of salivary glands FNAs can be used for accurate diagnosis, educational and second opinion purposes,. They can also be used for archiving, teleconsultation and educational purposes, improving the performance of the already existing static telecytology stations and small cytology departments' quality indices.

Implementation of pre-captured videos for remote cytological evaluation of salivary gland lesions

OBJECTIVE

The objective of this study was to examine the feasibility of implementing videos captured by static telecytological applications for remote cytological evaluation of fine needle aspiration specimens from salivary gland lesions.

METHODS

The current study was carried out on 102 fine needle aspiration specimens from salivary gland lesions with histological confirmation (benign lesions, 11; benign neoplasms, 68; malignant neoplasms, 23), retrospectively selected from the department's registry. Videos were transferred via file transfer protocol to password-protected accounts for remote review by three independent cytopathologists. In addition to diagnosis, reviewers commented on overall digital video quality. Contributor's and reviewer's diagnoses were collected, recorded and statistically evaluated.

RESULTS

Statistical evaluation of cytological diagnoses detected no significant difference in diagnostic accuracy between the diagnoses proffered on the basis of pre-captured videos and conventional slides. The overall interobserver agreement was ranging from substantial to almost perfect with κ values of 0.71-0.89.

CONCLUSIONS

Video production by static telecytology applications can be used as an alternative method for telecytological diagnosis of salivary gland fine needle aspirations. Videos of salivary gland fine needle aspirations can be used for rapid and accurate diagnosis, by diminishing turn-around times and improving the quality indices of small cytology departments. They can also be used for archiving, teleconsultation, educational and second opinion purposes, improving the performance of the already existing static telecytology stations.

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.

Learning cytology in times of pandemic: an educational institutional experience with remote teaching

Introduction

As the coronavirus pandemic swept across national and state borders, institutions of higher learning, including cytology, began closing campuses and moving instruction online. We have described a method of remotely teaching cytology in our institution, including using the telecytology concept used with rapid onsite evaluation and remote conferencing and educational tools to conduct eCytology learning. This is a cost-effective method to transition a traditional in-classroom program into online teaching for cytology. It can also be implemented quickly.

Materials and methods

In March 2020, our cytology program developed a method for teaching cytology remotely. The distance-learning teaching method included the use of remote conferencing (Zoom platform) and learning management platforms (Canvas) to present lectures and administer tests. Remote multihead sessions were conducted by adapting the telecytology rapid onsite evaluation concept, which attaches a mobile device to the microscope to transmit live video to remote learners.

Results

When asked about their experience with online learning, the students had responded positively. All the students indicated a willingness to attend classes remotely in the future, even when the traditional in-classroom learning option is available.

Conclusions

We have presented a method for educating students remotely using existing technology that is affordable and can be implemented quickly by nearly all cytology education programs.

•

Our experience with teaching eCytology in times of pandemic can serve as a cost-effective way to transition a traditionally in-classroom program, into an online teaching in cytology. It can also be implemented quickly.

•

Remote multi-head sessions, conducted by adapting the tele-cytology ROSE concept with an attached mobile device to the microscope, is an effective approach to distance learning in times of social distancing and is a promising tool for the future cytology education.

•

The students, when asked about their experiences with online learning, responded positively.

Rapid On-Site Evaluation With Telecytology Significantly Reduced Unsatisfactory Rates of Thyroid Fine-Needle Aspiration

OBJECTIVES

We evaluated telecytology rapid on-site evaluation (ROSE) for thyroid ultrasound-guided fine-needle aspiration. To the best of our knowledge, this study is the first case-control clinical trial of thyroid telecytology.

METHODS

We introduced on-site ROSE in our institution's thyroid clinic for 6 months, followed by telecytology for 12 months. Our institution's ultrasound clinic, where ROSE is not provided, was used as a control group for each period.

RESULTS

Both groups had similar initial unsatisfactory rates (thyroid clinic: 8.8%; ultrasound clinic: 8.0%) before the study began. The thyroid clinic's unsatisfactory rate was significantly reduced to 1.6% after on-site ROSE (P = .001) and to 3.8% after telecytology ROSE (P = .010), with no significant difference between on-site and telecytology ROSE periods (P > .05). The ultrasound clinic's unsatisfactory rate was unchanged for both periods. Concordance between telecytology ROSE and final adequacy was 97% (κ = 0.699).

CONCLUSIONS

Telecytology ROSE reduces unsatisfactory rates for ultrasound-guided fine-needle aspiration without compromising patient care.

The Role of Telecytology in the Primary Diagnosis of Thyroid Fine-Needle Aspiration Specimens

INTRODUCTION

The Acibadem Health Group (AHG) has been using telepathology/digital pathology stations since 2006. In 2013, the system was changed from videoconferencing to digital pathology (whole-slide imaging) utilizing 3DHISTECH scanners and software. In 2017, digital cytology started to be used for routine cytopathologic diagnosis for thyroid fine-needle aspiration (FNA) cases.

MATERIAL AND METHODS

Two hundred and twenty-seven thyroid cases were received for analysis using telecytology (TC) during the period from November 2017 to May 2018. Rapid on-site evaluation was performed at the Atakent Hospital of the AHG by a cytotechnologist and scanned on the same day. For every case, there were Diff-Quik- and Papanicolaou-stained FNA smears. Each glass slide was digitized with a 3DHISTECH whole-slide scanner in 1 focal Z-plane at ×40 magnification.

RESULTS

Two hundred and twenty-seven thyroid FNA specimens were retrieved, of which 25 had histologic follow-up. Samples were classified as nondiagnostic in 3%, benign in 74%, atypia of undetermined significance/follicular lesion of undetermined significance in 13%, suspicious for follicular neoplasia/follicular neoplasia in 3%, suspicious for malignancy in 4%, and malignant in 3%. When only the "suspicious for malignancy" and "malignancy" categories were considered positive tests, cytology sensitivity and specificity using TC for diagnosis was 100%.

CONCLUSIONS

Our data demonstrate that TC is suitable to provide a primary diagnosis in daily routine cytology practice. Despite the promising results, there were some challenges stemming from the novelty of using TC for the primary diagnosis. The study also addresses both advantages and disadvantages of TC in daily practice to increase the efficiency of the technique in primary diagnosis.

Comprehensive Study of Telecytology Using Robotic Digital Microscope and Single Z-Stack Digital Scan for Fine-Needle Aspiration-Rapid On-Site Evaluation

Background:

The current technology for remote assessment of fine-needle aspiration-rapid on-site evaluation (FNA-ROSE) is limited. Recent advances may provide solutions. This study compared the performance of VisionTek digital microscope (VDM) (Sakura, Japan) and Hamamatsu NanoZoomer C9600-12 single Z-stack digital scan (SZDS) to conventional light microscopy (CLM) for FNA-ROSE.

Methods:

We assembled sixty FNA cases from the thyroid (n = 16), lymph node (n = 16), pancreas (n = 9), head and neck (n = 9), salivary gland (n = 5), lung (n = 4), and rectum (n = 1) based on a single institution's routine workflow. One Diff-Quik-stained slide was selected for each case. Two board-certified cytopathologists independently evaluated the cases using VDM, SZDS, and CLM. A “washout” period of at least 14 days was placed between the reviews. The results were categorized into satisfactory versus unsatisfactory for adequacy assessment (AA) and unsatisfactory, benign, atypical, suspicious, and malignant for preliminary diagnosis (PD).

Results:

For AA, the Cohen's kappa statistics (CKS) scores of intermodality agreement (IMA) were 0.74–0.94 (CLM vs. VDM) and 0.86–1 (CLM vs. SZDS). The discordant rates of IMA were 3.3% (4/120) for VDM versus CLM, and 1.7% (2/120) for SZDS versus CLM. For PD, the CKS scores of IMA ranged 0.7–0.93. The overall discordant rates of IMA were 15% (18/120) for CLM versus VDM and 10.8% (13/120) for CLM versus SZDS. The discordant rates of IMA with 2 or higher degrees were 5.8% (7/120) for CLM versus VDM and 1.7% (2/120) for CLM versus SZDS. The average time spent per slide was 270 s for VDM, significantly longer than that for CLM (113 s) or for SZDS (122 s).

Conclusions:

Our data demonstrate that both VDM and SZDS are suitable to provide AA and reasonable PD evaluation. VDM, however, has a significantly longer turnaround time and worse diagnostic performance. The study demonstrates both the potentials and challenges of using VDM and SZDS for FNA-ROSE.

On the job training: an educational program in ROSE of fine needle aspirates and telecytology for cytotechnologists

INTRODUCTION

As the demand for rapid on-site evaluation (ROSE) of fine needle aspirates (FNAs) has continued to increase, the provision of service requires a creative approach to maximize efficiency without compromising patient care. We describe the educational process used to train cytotechnologists in ROSE of FNAs using telecytology.

MATERIALS AND METHODS

In 2005, the cytopathology division of the University of Wisconsin pathology department developed an on the job training program for cytotechnologists in ROSE of FNAs using telecytology. Training includes education in assistance on FNA procedures, proficiency and competency in specimen adequacy assessments, and proper usage of the telecytology work station. Trainees are monitored by a trainer through all the steps of the process, including the checklists and examination.

RESULTS

Eight cytotechnologists successfully completed the program, with test scores ranging from 90% to 95%, and were deemed competent by all measures to provide ROSE of FNAs via telecytology.

CONCLUSIONS

Cytotechnologists play a pivotal role in the provision of an FNA service. Schools of cytotechnology should educate students (future cytotechnologists) in ROSE of FNAs and video streaming via telecytology to prepare them for clinical work, enhance their scope of practice, and improve their job satisfaction.

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.

Digital Applications in Cytopathology: Problems, Rationalizations, and Alternative Approaches

OBJECTIVE

The aim of this work was to raise awareness of problems using digital applications for examining, teaching, and applying telecytology at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia; University of Nebraska Medical Center (UNMC), Omaha, NE, USA; and University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA. The objective was to rationalize problems and propose alternative digital approaches.

STUDY DESIGN

We sought to identify solutions to improve the following: (a) interpretive examination scores at KAMC for complex cytological templates (i.e., high-grade squamous intraepithelial lesions [HSIL]) when using static digital images (SDI) of cells in regions of interest (ROI); (b) visualization of cells in 3D clusters when teaching at UNMC using 2D and 3D whole-slide imaging (WSI); and (c) visualization of cells through streaming telecytology at UPMC.

RESULTS

Composite SDI (CSDI) improved test scores for complex interpretations (i.e., HSIL) by converging diagnostic criteria from multiple ROI. Multiplane focusing through z-stacked WSI facilitated the teaching of cytological entities characterized by 3D cell clusters and consultative telecytology through robotic cell analysis.

CONCLUSIONS

Adequately visualized cytomorphology and multiplane focusing are essential for virtual cytopathology examinations, teaching, or consultative telecytology. Visualization of diagnostic criteria through 2D or 3D imaging is critical. Panoptiq panoramic WSI with integrated z-stacked video clips enables optimal applied telecytology.

Inexpensive telecytology solutions that use the Raspberry Pi and the iPhone

INTRODUCTION

There is currently substantial interest in dynamic telecytology-the presentation of microscopic findings by live video feed to a cytopathologist at a remote location. However, the initial costs of a telecytology system can be high. We present several low-cost alternatives along with their performance characteristics.

MATERIALS AND METHODS

We tested 3 low-cost telecytology systems: a Raspberry Pi with a webcam, an iPhone 4S with FaceTime, and an iPhone 4S with a live streaming app. Costs, resolution capacities, and latency periods for image transmission were determined.

RESULTS

At $85.55, the Raspberry Pi system is the least expensive telecytology solution described to date. When the cost per megapixel of resolution is considered, the cost of a Raspberry Pi system is 120× less than the most expensive commercially available option and about 7-fold less than the iPhone-based alternatives. Latency periods were substantially lower for the iPhone systems: 2.5 ± 1 seconds for FaceTime and 2.8 ± 0.3 seconds for iPhone live streaming versus 6.6 ± 0.6 seconds for the Raspberry Pi system at comparable frame rates.

CONCLUSIONS

This proof-of-principle study demonstrates that inexpensive telecytology systems are able to stream live video feeds of cytology slides from a microscope to a remote location at useable resolutions.

Cytotechnologists and on-site evaluation of adequacy

While fine needle aspiration (FNA) is certainly not a new biopsy technique, recent developments in advanced imaging techniques, molecular testing, and targeted therapies have coincided with a rapid increase in the number of FNA procedures being performed. Concurrently, the demand for on-site evaluation of adequacy (OSEA) has also increased, outstripping the capacity of available cytopathologists at some institutions. Among the several alternatives to cytopathologist-performed OSEA, cytotechnologist-attended OSEA stands out because it preserves the representation of the pathology service at the time of the procedure. Herein, we review the current literature about OSEA and the necessity of cytotechnologists to expand access of this useful pathology service to a broader patient population. We also examine how cytotechnologists are likely to fit into the emerging practice of telecytology.