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Cytopathology

Cytopathology in focus: How to approach cytology of unknown primary

August 2023—We discuss in this article a common problem that all cytopathologists come across frequently in their practice: tumors of unknown primary origin involving body fluids and other sites. Metastatic tumor cells can disseminate and colonize discontinuous secondary body sites.1 Such tumor metastases may be the patient’s initial presenting complaint to a family physician for deep-seated tumor primaries such as ovaries, pancreas, liver, and certain non-obstructive gastrointestinal tumors.

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Cytopathology in Focus: Lung cytopathology reporting: WHO system and cases

August 2023—Accurate and timely diagnosis is the cornerstone of effective patient care, particularly in the field of pulmonary pathology. To address the challenges health care professionals face in diagnosing and reporting respiratory conditions, the International Academy of Cytology, together with the International Agency for Research on Cancer, recently developed the World Health Organization Reporting System for Lung Cytopathology

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Cytopathology in focus: Protocol for reporting cervicovaginal cytology specimens

August 2022—The protocol for the reporting of cervicovaginal cytology, the first in a series of CAP cytopathology protocols, became available for use in a synoptic format on June 22. This protocol is a collaborative effort, based on input from past and present members of the CAP Cytopathology Committee and prepared in conjunction with the CAP Pathology Electronic Reporting Committee. It was presented via webinar to the CAP House of Delegates on March 31. A two-week open comment period followed; all comments were reviewed and appropriate changes were incorporated into the protocol.

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Cytopathology in focus: Advances in detection of mesothelioma in cytology pleural fluid specimens

August 2022—The ability to make a definitive diagnosis of mesothelioma on pleural fluid cytology has been questioned and debated for a long time. The 2018 American Society of Clinical Oncology clinical guidelines limit the cytological diagnosis of pleural fluid specimens only as an initial screening test for mesothelioma. Monaco, et al., discuss in their article the appropriate use of ancillary studies (immunohistochemistry and fluorescence in situ hybridization studies) to make a definitive diagnosis of mesothelioma in small tissue samples, which are often processed as cell blocks. The authors recommend a stepwise approach starting with immunohistochemistry for BAP1 and, next, MTAP in cases of atypical mesothelial proliferations where the suspicion for malignant mesothelioma is high.

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Cytopathology in focus: ROSE and telecytopathology: a point-of-care test

May 2022—Substantial progress has been made during the past several years in diagnosing and treating various illnesses. Advances in genetic and genomic science; imaging and localization devices; the use of minimally invasive diagnostic sampling procedures; diagnostic, prognostic, and predictive testing; and personalized therapeutic options—all have changed the pattern of the practice of medicine and how patient care is provided.

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Cytopathology in focus: The cytopathology workforce through a DEI lens

May 2022—The ineffectiveness of the U.S. health care system is well documented. The United States consistently allocates more resources for health care compared with other industrialized countries, while not holding the top spots for desired outcomes. A significant percentage of Americans is underinsured or uninsured, and access to quality care is widely asymmetrical among different racial and ethnic groups. Early in the pandemic, COVID-19 highlighted these health inequities in which Blacks, Hispanics, Native Americans, and immigrants were the populations to disproportionately experience disparities related to burden of disease and mortality.

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Cytopathology in focus: Know the accreditation requirements for telecytology

May 2022—The number of minimally invasive fine-needle aspirations requiring rapid on-site evaluation (ROSE) in the cytopathology laboratory has increased over the past decade. Laboratories have seen lower gynecologic volumes and an increase in both nongynecologic fine-needle aspiration biopsy and touch imprint samples. ROSE for patient care has proven value. Sample adequacy allows for a single visit and avoids having to make multiple attempts to provide material sufficient for all required testing, including flow cytometry, microbiology, cell block preparation for immunohistochemical and histochemical staining, and molecular testing.

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Cytopathology in focus: Reflections on use of Milan System, edition 1: Areas to be explored for edition 2

August 2021—Salivary gland neoplasms (SGN) are a special group of tumors due to the high variation in histologic subtypes that are further complicated by frequent overlapping morphological features. Fine-needle aspiration is a safe, cost-effective, first-line modality for diagnosing SGNs, an integral part of SGN preoperational workup. In 2018, Faquin and Rossi led the effort to standardize the reporting system of salivary gland lesions. Their final product, Milan System for Reporting Salivary Gland Cytopathology (MSRSGC), has had a huge impact on salivary gland FNA practice in the United States and worldwide.

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Cytopathology in focus: At the center of AI implementation in cytopathology

August 2021—Recent advances in the deep learning area of artificial intelligence offer tantalizing opportunities to improve cytology practice. However, aside from the commercially available options for automated screening in gynecologic cytology, systems with applications in cytology have largely been used in research settings only. The article by authors McAlpine and Michelow reviews the approach to developing and validating artificial intelligence algorithms in cytology, from the generation of appropriate cytology data sets to clinical validation of the model.

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Cytopathology in focus: Inspection pitfalls: Common cytology lab-related deficiencies

May 2021—As COVID-19 restrictions ease, many laboratories are ramping up for biennial CAP inspections. Some of these inspections were delayed due to COVID restrictions and others were performed virtually and now must complete the statutory requirement of an on-site inspection. To add to the mix, the CAP published its 2020 checklist edition earlier than usual because of its impending reapplication with the CMS for deeming authority as an accrediting organization under CLIA. Together, these have made the 2021 inspection process appear unusually daunting. While no laboratory is immune to inspection anxiety, it does help to arm oneself with the knowledge gathered from the collective experiences of peers and colleagues across the country. Knowing what the common inspection pitfalls are can bring us a step closer to the “utopia” of a flawless inspection.

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Cytopathology in Focus: What breast cytology brings to rapid assessment clinics

May 2021—During the past several years, significant changes have occurred in the approach to the diagnosis and follow-up of patients with breast cancer. The scattered and fragmented breast health services have been replaced by patient-centered clinical breast units and rapid assessment breast clinics all over the world.Pioneered and implemented in European countries, rapid assessment breast clinics are designed to effectively assess symptomatic women with palpable breast lesions by fine-needle aspiration biopsy (FNAB).

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Cytopathology in focus: Virtual education in cytology: pandemic silver lining

January 2021—Although the challenges we face due to the COVID-19 pandemic are significant, adapting to our new circumstances can be a driver for positive change. Cytology education had started using virtual learning resources in the past few years with great variation among institutions and countries. The pandemic forced the community to embrace virtual learning in a variety of modalities. These changes may lead to lasting improvements in the quality and accessibility of educational opportunities for cytology trainees, and not just in the United States. In the same way, we are witnessing the exponential growth of digital pathology as applied to surgical pathology. In cytopathology the applications have been limited to telecytopathology in the setting of rapid on-site evaluation (ROSE) for interventional procedures. The difficulties in dealing with multilayered focus have been given as reasons not to pursue whole slide imaging for cytology. As the cytology community has, even if reluctantly, gained experience with remote sign-out, we may see a push for digital imaging for primary diagnosis in cytology.

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Cytopathology in focus: Telecytology for rapid on-site evaluation

January 2021—Rapid on-site evaluation (ROSE) for cytology specimens is performed at many institutions to improve the quality of health care by proper triage of obtained material to increase the diagnostic yield, or to direct appropriate investigation. It also helps to control health care costs by reducing the rate of nondiagnostic specimens, unnecessary passes, and repeat procedures. The number of procedures requiring ROSE is growing due to the increase in the number of platforms used to perform minimally invasive procedures.

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Cytopathology in focus: Abnormal cervical screening tests: a personal approach

August 2020—If the past decade was directed toward aligning medicine with a personalized approach to therapy, this decade should further realize the implementation of health care decisions tailored to the patient. The updated 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors take a large step in that direction by relying on the input of personal data into a free online application that provides suggested management planning based on patient history and prior Pap/HPV test results.

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Cytopathology in focus: New direction for thoracic small biopsy, cytology specimens

August 2020—Cytopathologists are keenly aware of the need to collect adequate cytologic tissue not only to arrive at a diagnosis but also to provide sufficient material for predictive and prognostic markers. This is especially true in the realm of non-small cell lung cancer, where biomarker testing is routinely used for the clinical management of patients with advanced-stage disease. The list of clinically relevant biomarkers in NSCLC is expanding. The most recent version of the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology includes MET exon 14 skipping mutations and RET as therapeutic targets for advanced NSCLC, in addition to the well-established EGFR and BRAF mutations, ALK and ROS1 rearrangements, and PD-L1 expression.

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Cytopathology in focus: Direct HPV testing in FNAs from cervical lymph node metastases

May 2020—According to a Centers for Disease Control and Prevention study from 2008 to 2012, there are about 16,000 cases of HPV-positive oropharyngeal squamous cell carcinoma per year in the United States. These carcinomas tend to present with small primary lesion and early nodal metastases as an initial manifestation of the disease. Furthermore, carcinoma of unknown primary presenting as a cystic metastasis in the head and neck has been linked frequently to oropharyngeal squamous cell carcinomas, mainly of palatine tonsils and base of the tongue.

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Cytopathology in focus: Gynecologic cytology PT appeals: where they started,where they stand

May 2020—The CAP implemented proficiency testing for cervical cytology in 2006 as mandated by federal legislation. The performance of participants and granting of appeals on glass slides in the first year of the CAP Pap PT program was reported in detail by Crothers, et al. Once a participant initiates an appeal, the slide in question is pulled from the program for a blinded review by three board-certified anatomic pathologists who are members of the CAP Cytopathology Committee. In the first year, 155 participants failed the PT examination and appealed their testing results on 86 individual slides. After review, appeals were granted for 21 slides, resulting in 45 exam failure reversals. The overall appeal rate was 13/1,000 slides in the program.

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Cytopathology in focus: Can you send us your cytology slides? Labs are reimbursed for slides accepted into programs

May 2020—The CAP relies on the generous submission of slide-based cases from laboratories to maintain the excellent quality of its Cytopathology Educational Programs in Gynecologic Cytopathology (Pap Education), Non-Gynecologic Cytopathology (NGC), Fine Needle Aspiration Cytopathology (FNA), and Proficiency Testing Program in Gynecologic Cytopathology (Pap PT). The CAP Cytopathology Committee, composed of 26 pathologists, two junior members, and two cytotechnologist members, meets quarterly and members submit glass slides to these varied programs.

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Cytopathology in focus: Non-small cell lung carcinoma

January 2020—Requests for predictive biomarkers in oncology patients are becoming increasingly common in the cytology laboratory. At the time of rapid on-site evaluation, cytologists are now keenly aware of the need to collect adequate material not just for a diagnosis of malignancy but also for diagnostic and predictive molecular and immunohistochemical testing. This article provides an overview of current practices and some of the recent literature regarding predictive testing for immunotherapy in cytologic preparations in non-small cell lung carcinoma.

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Cytopathology in focus: Self-collected Pap tests in the U.S. market

January 2020—The authors of an article published in the Journal of the American Society of Cytopathology participated in a public hearing at the Food and Drug Administration in January 2018. The hearing advised the FDA about what research would be required to demonstrate the safety and efficacy of a self-collected Papanicolaou test device. In the article, Staats, et al., review the literature on self-collected Pap tests. The authors also provide a review of published studies on self-collected HPV tests. They pose important questions that surround the self-collected Pap test; most remain only partially answered, given the limited evidence examining such tests in the literature.

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Cytopathology in focus: Review of FDA-approved molecular testing platforms for HPV

January 2020—The Food and Drug Administration approved in 2001 the first testing modality for the detection of HPV in gynecological cytological specimens. To date, there are now five FDA-approved testing modalities, and molecular testing for high-risk HPV has become commonplace. Numerous studies have shown that high-risk HPV testing is more sensitive in detecting high-grade squamous intraepithelial lesion/cervical intraepithelial neoplasia grade two and above (HSIL/CIN2+) than cytology alone, but that cytology is more specific.

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Cytopathology in focus: Lab performance in 2018—a year-end tally

August 2019—The CAP has a long-standing commitment to education in cytopathology, with a number of organized educational offerings in gynecologic and nongynecologic cytopathology. The Interlaboratory Comparison Program in nongynecologic cytopathology (NGC Education) was started in 1997 and the Interlaboratory Comparison Program in fine-needle aspiration glass slide education (FNAG) in 2010. These programs are strictly educational and not graded or used for proficiency testing. Semiannual (FNAG) and quarterly (NGC) mailings include four or five cases. For each case, glass slides generally stained with a Diff-Quik and/or Pap stain are provided.

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Cytopathology in focus: BD Onclarity HPV assay now in CAP HPV Surveys

August 2019—The BD Onclarity HPV assay is a human papillomavirus test approved by the Food and Drug Administration on Feb. 12, 2018. The assay is a qualitative test for detection of HPV in cervical specimens collected either with a broom or endocervical brush/spatula combination and placed in a BD SurePath liquid-based cytology vial. The assay is not approved for use with ThinPrep collection media (PreservCyt).

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Cytopathology in focus: Updated NSCLC guideline moves molecular cytopathology forward

May 2019—The genomic landscape of non-small cell lung carcinoma is evolving constantly with the discovery of a growing number of molecular alterations and associated targeted therapies that have an impact on patient care. The CAP, International Association for the Study of Lung Cancer, and Association for Molecular Pathology issued a guideline in 2013 to provide a road map for molecular testing to select patients for treatment with targeted tyrosine kinase inhibitors.

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Cytopathology in focus: What pathologist competencies are monitored and how

May 2019—The CAP regularly surveys the practices of the laboratories participating in the CAP Nongynecologic Cytopathology Education Program, or NGC. Members and staff of the CAP Cytopathology Committee developed a supplemental questionnaire eliciting feedback on pathologist competency activities. The Survey was mailed to 2,142 participants in the NGC-B 2018 education program. The pathologist competencies queried were as follows:

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Cytopathology in focus: Exchange of views—HPV screening policies in Australia

May 2019—In the November-December 2018 issue of the Journal of the American Society of Cytopathology is a fascinating analysis of human papillomavirus screening policies in Australia by researchers from New Zealand, a rebuttal by members of an Australian Cervical Cancer Screening Guidelines Working Party, and a thoughtful editorial by cervical cancer screening experts from the United States and England.

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Cytopathology in focus: How can a lab ensure individual competence?

January 2019—It is happening again: CAP members and cytotechnologists are asking about regulatory requirements for re-integrating into cytopathology after a period of practice latency. That is good news because it indicates that they are interested in practicing at a time when the cytopathology community can use skilled professionals. The past decade has seen a shrinking volume of Pap tests and a concomitant decline in the number of practicing cytologists, which has created new job opportunities for those with cytopathology skills.

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Cytopathology in Focus: Synergy in cytopathology and molecular microbiology

August 2018—In today’s less-is-more world, health care consumers and providers often seek explicit and detailed information from minimally invasive procedures and tiny samples. Over are the days of “malignant cells present” and on to the next case. Cytopathologists and cytotechnologists are embracing and integrating novel techniques and applying new methods to the diagnosis and classification of essentially every imaginable form of neoplasia. The 2018 WHO publications confirm that 29 percent of deaths worldwide (more than 10 million people annually) are attributable to communicable diseases.1,2 This means the purpose of procuring many specimens is not to just rule out malignancy but also to diagnose infectious etiologies.

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Cytopathology in Focus: Why not call everything ASCUS?

August 2018—Below is a question shared on the ASC listserv. My reply to the question follows. A pathologist colleague who practiced previously as an obstetrician/gynecologist is of the opinion that categorizing the level of abnormality we observe on a Pap test is a waste of time. All the clinician needs to know, he says, is whether the test is normal or abnormal. The Pap test is a screening test, he says correctly, and its only relevance is in pointing out who needs a colposcopy and biopsy.

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Cytopathology in Focus: Reporting salivary gland cytopathology—new user-friendly Milan system consists of six diagnostic categories

May 2018—The Milan System for Reporting Salivary Gland Cytopathology was published Jan. 31 and is an important step toward standardizing the reporting of salivary gland fine needle aspiration. A large body of literature has demonstrated that FNA is an effective method for the initial evaluation of salivary gland masses, but until this year there was no uniform, widely accepted reporting system. The complexity of salivary gland cytology poses unique challenges that demand a standardized approach to communication of diagnostic information between pathologists and treating clinicians.

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Cytopathology in Focus: For thyroid cytopathology, the 2017 Bethesda System

May 2018—Surgical pathologists take their tumor nomenclature from the WHO Classification of Tumours, but cytopathologists take their terminology from where the consensus groups convened—Bethesda, Paris, Milan, and Yokohama—to formulate terminology recommendations. The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC)1 is now in its second edition.

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Cytopathology in Focus: Standardized reporting for breast FNAB cytology

January 2018—In countries with developed medical infrastructure, the use of breast fine-needle aspiration biopsy (FNAB) cytology has had its share of challenges over the past 20 years, among them the use of core needle biopsies. In developing countries where the use of FNAB cytology has been increasing rapidly, breast lesions are one of the most common sites sampled by FNAB. In 2016, the International Academy of Cytology Executive Council put together a “Breast Group,” which consists of cytopathologists, surgical pathologists, radiologists, surgeons, and oncologists working in breast care, with the aim of producing a comprehensive and standardized approach to breast FNAB cytology reporting.

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Cytopathology in Focus: A right and a wrong way to use CAP educational kits

January 2018—The CAP Cytopathology Committee constructs educational and interlaboratory comparison kits that are distributed regularly to cytotechnologists, cytopathologists, and pathologists who want continuing education in cytopathology. The purpose of the kits is to make it possible for those who screen and diagnose cytology slides to maintain and update their skills. However, the Cytopathology Committee has been made aware that the kits have been employed for purposes other than education. We address here the potentially detrimental uses to which some laboratories are putting these educational kits and advise laboratories to use them only as they were intended.

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Cytopathology in Focus: HPV vaccines: the decade in review

January 2018—Diane Harper, MD, MPH, and Leslie DeMars, MD, provide an extensive review of the efficacy of available FDA-approved HPV vaccines in different age groups and describe immunogenicity findings in particular (Gynecol Oncol. 2017;146:196–204). The World Health Organization and the Centers for Disease Control and Prevention recommend a two-dose vaccine for younger children due to high rates of seroconversion and antibody titers in this age group. Girls age 15 and older should continue to get three doses.

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