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Detection of Malignancy in Body Fluid Cytology: A Comparison of the Hematology and the Cytology Laboratory
Abstracts
S113
207 Variation and Satisfaction in Cell Block Preparation: Assessment of Methods and Current Issues in Different Practice Settings Sara Monaco, MD1, John Crapanzano, MD2, Aziza Nassar, MD3, Anjali Saqi, MD, MBA2. 1Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; 2Pathology and Cell Biology, Columbia University Medical Center, New York, New York; 3Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota Introduction: Most laboratories utilize different preparations for cytological diagnoses, including Diff-Quik and Papanicolaou-stained smears, liquid-based preparations, and/or hematoxylin and eosin stained cell blocks (CBs). CBs can reveal the histological features of the cell population, in addition to providing small tissue fragments and material for ancillary studies, such as immunohistochemical stains and molecular studies. Compared to other cytological preparations, formalin-fixed CBs permit routine processing in a manner similar to that of surgical biopsy specimens. As the clinical demand for ancillary tests on cytological material increases for patient management, there is a growing necessity to provide sufficient material for these tests. The aim of the current study was to assess the different CB preparation techniques utilized in various practice settings and to analyze the current satisfaction level and/or issues. Materials and Methods: A link to an electronic survey was distributed via email to members of the American Society of Cytopathology and other cytotechnologists and cytopathologists. Eleven questions pertaining to the participants’ type of practice setting, CB volume, CB method, CB quality, and satisfaction were included in the survey. Results: Of 92 respondents, 86 (93%) completed the survey and comprise the basis of this study. Most participants practice in a community hospital/ private practice (48%) or an academic center (42%). On average, 14 CBs (range 0-50; mode 15) are prepared by a laboratory daily; only one respondent did not make CBs. Over 15 different methods are utilized and include plasma thrombin (36%), histogel (29%), the Cellient Automated Cell Block System (CACBS) (9%), and other methods (33%) (See Table). Many respondents (43%) are either unsatisfied or sometimes satisfied with the quality of CBs prepared in their laboratories, with low-cellular yield being a leading cause of dissatisfaction. The main reason(s) for utilizing or not utilizing CACBS include the enhanced cellular yield and the high cost, respectively. Sixty-seven percent of those surveyed would consider adopting an alternative method to process CBs. Table 1
Various Methods for Preparing Cell Blocks
CytoRich red pellets Formalin/alcohol mix OR agar Zinc formalin or agar Pick out large fragments 2% agar
Sedimentation EtOH/concentration/filter
Penfix/Formalin 5% alcoholic formalin
Formalin Manual centrifuge and fix Spin down and put in 10% formalin
Naturally forming clots Colloidin bag Albumin
Conclusions: Based on the survey, there is no consistent method to prepare CBs, and many respondents are dissatisfied with their current method of CB preparation. The survey highlights that there is a need for an economical and standardized protocol for optimization of CBs to enhance cellularity in today’s era of personalized medicine with an increasing array of molecular tests being applied to cytological specimens. 208 Under-reporting of Lubricant in Unsatisfactory Liquid-Based Pap Tests Julie Jackson, MD, Grazina Chatt, CT(ASCP), Eva Wojcik, MD, Güliz Barkan, MD. Pathology, Loyola University Medical Center, Maywood, Illinois Introduction: While effects of lubricant used during speculum examination have been well studied in conventional Pap tests, the effects on liquid-based
tests are less well characterized. Studies show, however, that potential exists for some water-based lubricants to interfere with ThinPrep (TP) Pap Tests. Our aim is to study the role of lubricant in unsatisfactory (unsat) TP Pap Tests and its impact on patient follow-up. Materials and Methods: All cases of unsat Pap tests due to low cellularity, too few squamous cells, lubricant, obscuring blood, or unspecified reasons were identified from a one year time period, and slides reviewed for presence of lubricant by a cytotechnologist and pathologist. Lubricant was considered present when a grainy, amorphous basophilic material was seen with associated clumping and obscuring of squamous cells. Electronic medical records were reviewed for clinical follow-up data, and chi squared test used for statistical analysis. Results: 212 unsat Pap Tests obtained by 53 clinicians were available for review. Upon review, lubricant was identified in 102(48%) of cases. Lubricant was identified significantly more often in cases reported as unsat due to low cellularity compared to those reported as unsat for all other reasons (p<0.001). Of patients with lubricant identified (mean age 49.6, range 18-83), 5 had prior history of endometrial cancer, 7 cervical cancer, 11 cervical dysplasia, and 3 abnormal vaginal bleeding. 32(31%) unsat Pap Tests with lubricant present were repeated, while 70 (69%) were never followed-up with a repeat Pap Test. Of the repeated Pap Tests, diagnoses were as follows: 21 negative, 8 unsatisfactory, and 3 ASCUS with negative HPV test. Identification of Lubricant in Unsatisfactory Pap Tests Reported Reason for Unsatisfactory Pap Test
Total Cases (n)
Lubricant Present on Review (n)
(%)
All Reasons Low Cellularity Obscuring Blood Lubricant Too Few Squamous Cells Unspecified
212 168 33 3 3 5
102 94 3 3 1 1
48% 56% 9% 100% 33% 20%
Conclusions: In our study, lubricant material was present in over half of cases diagnosed as unsat due to low cellularity, and presence of lubricant was significantly more likely in cases reported as unsat due to low cellularity than in cases reported as unsat due to other causes. Further, presence of lubricant was noted in the initial diagnosis in only 3 of these cases, suggesting that lubricant is likely being under-recognized and under-reported. By providing feedback to clinicians about lubricant in their reports, pathologists may help to reduce missed screening opportunities in these patients as many patients do not follow-up after unsat paps, reduce cost to the laboratory, hospital and clinician for repeated patient visits and Pap Tests, and more importantly, minimize inconvenience to the patient. 209 Detection of Malignancy in Body Fluid Cytology: A Comparison of the Hematology and the Cytology Laboratory Jaclyn Jerz, MD, Rachel Donohue, MD, Dina Mody, MD, Arthur Zieske, MD. Pathology and Genomic Medicine, The Methodist Hospital, Houston, Texas Introduction: Body fluid specimens submitted to hematology laboratories primarily for cell counting are also examined for the presence of malignancy. Many of these fluids are also submitted to cytology. We queried if it makes a difference whether a fluid is sent to the hematology or cytology laboratory. Materials and Methods: Quality assurance of the practice of identifying malignancy in body fluids by the hematology laboratory in our institution was assessed in a retrospective study. Cytologic or subsequent surgical pathologic diagnosis was considered the gold standard. Two hundred and ten body fluid specimens submitted to the hematology laboratory over two separate two month periods were evaluated in order to include all attending hematopathologists on that service. 95 of the specimens had concurrently or subsequently submitted specimens to cytopathology.
S114 Results: Thirteen of the 95 cases (14%) were diagnosed as malignant on cytologic evaluation. Three of these malignancies were detected by the hematology laboratory (3/13 Z 23% sensitivity); ten were not. There were no false-positive results of malignancy by the hematology laboratory. A hematopathologist consult had occurred in all three cases of malignancy that were concordant (3/3 Z 100%) and in 7 of the 10 cases that were discrepant (70%). The Romanowsky stained hematology slides for the 10 discrepant cases were retrospectively reviewed by an experienced hematopathologist and a senior cytopathologist. There was agreement that a definitive diagnosis of malignancy could not be made on the 10 cases based on the hematology lab cell count preparations. Since there was a concurrent cytology specimen or one submitted within a few days of the hematology laboratory examination, the discrepancies had no evident impact on patient care. However, this has led to reevaluation of body fluid submission policies to hematology and cytology and to reflex triage to cytology in selected cases. This quality improvement study is ongoing and a subsequent evaluation after the implementation of new policy and clinician education will be performed. Conclusions: 1) Body fluid specimens processed for optimal cell counting are not ideal for identification of malignancy. 2) Clinicians need to be educated on the limitations of identifying malignancy in specimens submitted and processed for cell counting. 3) In the current era of avoiding duplicate testing and the growing pressures on physicians to decrease testing overall, cytologic examination has the potential of being sacrificed in the interest of cost containment. This could have grave consequences for patient care. 210 Reprocessing Unsatisfactory ThinPrepÒ Pap Tests by a Modified SurePathÔ Method Yields Diagnostic Cells Melissa Randolph, BS, CT(ASCP), Harvey Cramer, MD, Howard Wu, MD, William Crabtree, PhD, SCT(ASCP). Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, Indiana Introduction: Over the past three years our laboratory has reflexively reprocessed Unsatisfactory ThinPrepÒ Pap Test samples by a lab validated method using a modified SurePathÔ reprocessing technique. This procedure was initiated to determine if residual unsatisfactory ThinPrepÒ samples could be salvaged via an alternative processing technique to obtain diagnostic cells that would have otherwise been discarded. Materials and Methods: All unsatisfactory ThinPrepÒ Pap tests encountered during the 3-year period from 2009 through 2011 were reprocessed using a modified SurePathÔ method validated in the Indiana University Health Pathology Laboratory. Initially, 4ml of fluid was aliquoted from the specimen vial to fulfill needs of HPV testing. The remaining fluid was submitted for reprocessing by the modified technique. The slides were stained with the ThinPrepÒ Imaging Protocol Ô stain to minimize inter-observer variance and then examined by manual review. The original ThinPrepÒ slide was submitted along with the reprocessed slide to the pathologists for sign-out. A note was entered in the report alerting the clinician to the extra effort of recovery when a case remained Unsatisfactory for interpretation. For cases that were satisfactory and found to yield an epithelial cell abnormality, the case interpretation was based on the examination of the cells from the combined preparations. In all, 1937 ThinPrepÒ Pap Tests were reprocessed and examined. The data was then compiled for analysis. Results: 1093 (56%) specimens were successfully converted to a satisfactory sample, with 624 specimens (57%) showing evidence of a transformation zone. HPV testing was performed on 405 (38%) specimens with a High-risk positivity rate of 12% (49). Epithelial cell abnormalities were identified in 116 (10.6%) specimens. ASCUS diagnoses comprised 79 (7.5%), LSIL was found in 21 (1.9%), HSIL was found in 11 (1.0%) and ASC-H was found in 5 (.4%) specimens. No invasive carcinomas were identified. Conclusions: The modified SurePathÔ processing was adept at handling almost all of the challenges that biological conditions (blood, lubricant,
Abstracts protein, etc.) present to liquid-based filter preparations. 1093 (56%) of unsatisfactory ThinPrepÒ pap tests were converted to a satisfactory state and 116 (10.6%) of the specimens presented the opportunity of an otherwise undetected abnormality to be diagnosed. The reflexive reprocessing results mirrored the percentage and distribution of HSIL, ASC-H and ASC abnormalities found in the patient population statistically existing in our laboratory. LSIL and AGC abnormalities were detected less frequently in this patient population. Additionally, with this method there is no need to validate a change in assay methods from the use of glacial acetic acid treatment. The laboratory is able to fulfill clinical co-testing requests. Pathologists have benefited from the reduction of caseload resulting from the reprocessing effort and are able to focus on pap tests needing review. Most importantly, patients benefitted by the identification of abnormal cells in their samples that would have otherwise been discarded and lost to analysis. 211 Comparison of Cell Block Preparation Using HistoGel and Plasma Thrombin Techniques Vanessa Benkovich, BS, Jackie Cuda, SCT(ASCP), Walid Khalbuss, MD, PhD, Liron Pantanowitz, MD, Alka Palekar, MD, Sara Monaco, MD. Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Introduction: Cell blocks are a useful adjunct tool available for the preparation and evaluation of specimens in aspiration and exfoliative cytology. Cell blocks are advantageous in that they show tissue architecture and can provide material for ancillary testing (e.g. immunocytochemistry and molecular studies). Our goal was to assess and compare the preparation of cell blocks in our laboratory using a variety of different methods. Materials and Methods: Ten fluid specimens (8 pleural, 2 peritoneal) were utilized to prepare cell blocks in 6 different ways: 5 different methods using HistoGel (Thermo Scientific Richard-Allan ScientificHistoGel; Kalamazoo, MI) and 1 using plasma thrombin (PT) technique. HistoGel cell pellet preparations involved lifting (HLIFT), stirring (HSTIR), or vortexing (HVORTEX) the pellet, in addition to letting the gel settle undisturbed (HSETTLE) and vortexing with refrigeration (HVORTEXF). Four cytopathologists blindly evaluated H&E sections of the 6 cell blocks from 10 specimens, and scored them on a scale of 1 (suboptimal, worst) to 5 (optimal, best) evaluating cellularity, cell distribution, morphology, background, pellet size, and overall quality. Averages were then obtained and evaluated to compare satisfaction with each of the preparation methods. Results: Based on the overall rating, the PT technique scored the highest in 8 of 10 (80%) specimens. Of the HistoGel preparatory techniques, stirring and vortexing received the highest ratings. In general, the PT technique received higher scores than HistoGel for cellularity, morphology, cell distribution, and pellet size in samples of high and low cellularity. Table 1 shows the overall average score for each preparation method for the 10 samples. Table 1 Comparison of Overall Average Score for Cell block preparation methods in 10 fluid specimens Specimen # 1 2 3 4 5 6 7 8 9 10
PT
HLIFT
HSTIR
HSETTLE
HVORTEX
HVORTEXF
3.2 4.9 3.8 4.0 3.5 4.7 4.3 2.9 3.8 2.5
1.7 3.1 2.3 3.2 2.7 3.9 3.6 2.2 2.9 4.0
2.0 3.9 3.4 3.2 2.1 4.2 3.7 2.5 3.3 2.4
1.6 3.3 1.6 3.0 2.3 3.4 3.0 2.5 2.1 2.8
1.9 3.9 2.4 2.4 1.8 4.0 4.1 1.3 3.8 2.4
1.8 4.2 1.7 3.3 2.2 4.1 4.1 2.4 4.2 2.3
Legend: Plasma Thrombin (PT), HistoGel: Lifting (HLIFT), HistoGel: Stirring (HSTIR), HistoGel: Settle (HSETTLE), HistoGel: Vortexing (HVORTEX), HistoGel: Vortexing with refrigeration according to package insert (HVORTEXF)
Conclusions: Based on these data, the PT cell block method showed superior quality compared to cell blocks prepared in a variety of other ways
S113
207 Variation and Satisfaction in Cell Block Preparation: Assessment of Methods and Current Issues in Different Practice Settings Sara Monaco, MD1, John Crapanzano, MD2, Aziza Nassar, MD3, Anjali Saqi, MD, MBA2. 1Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; 2Pathology and Cell Biology, Columbia University Medical Center, New York, New York; 3Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota Introduction: Most laboratories utilize different preparations for cytological diagnoses, including Diff-Quik and Papanicolaou-stained smears, liquid-based preparations, and/or hematoxylin and eosin stained cell blocks (CBs). CBs can reveal the histological features of the cell population, in addition to providing small tissue fragments and material for ancillary studies, such as immunohistochemical stains and molecular studies. Compared to other cytological preparations, formalin-fixed CBs permit routine processing in a manner similar to that of surgical biopsy specimens. As the clinical demand for ancillary tests on cytological material increases for patient management, there is a growing necessity to provide sufficient material for these tests. The aim of the current study was to assess the different CB preparation techniques utilized in various practice settings and to analyze the current satisfaction level and/or issues. Materials and Methods: A link to an electronic survey was distributed via email to members of the American Society of Cytopathology and other cytotechnologists and cytopathologists. Eleven questions pertaining to the participants’ type of practice setting, CB volume, CB method, CB quality, and satisfaction were included in the survey. Results: Of 92 respondents, 86 (93%) completed the survey and comprise the basis of this study. Most participants practice in a community hospital/ private practice (48%) or an academic center (42%). On average, 14 CBs (range 0-50; mode 15) are prepared by a laboratory daily; only one respondent did not make CBs. Over 15 different methods are utilized and include plasma thrombin (36%), histogel (29%), the Cellient Automated Cell Block System (CACBS) (9%), and other methods (33%) (See Table). Many respondents (43%) are either unsatisfied or sometimes satisfied with the quality of CBs prepared in their laboratories, with low-cellular yield being a leading cause of dissatisfaction. The main reason(s) for utilizing or not utilizing CACBS include the enhanced cellular yield and the high cost, respectively. Sixty-seven percent of those surveyed would consider adopting an alternative method to process CBs. Table 1
Various Methods for Preparing Cell Blocks
CytoRich red pellets Formalin/alcohol mix OR agar Zinc formalin or agar Pick out large fragments 2% agar
Sedimentation EtOH/concentration/filter
Penfix/Formalin 5% alcoholic formalin
Formalin Manual centrifuge and fix Spin down and put in 10% formalin
Naturally forming clots Colloidin bag Albumin
Conclusions: Based on the survey, there is no consistent method to prepare CBs, and many respondents are dissatisfied with their current method of CB preparation. The survey highlights that there is a need for an economical and standardized protocol for optimization of CBs to enhance cellularity in today’s era of personalized medicine with an increasing array of molecular tests being applied to cytological specimens. 208 Under-reporting of Lubricant in Unsatisfactory Liquid-Based Pap Tests Julie Jackson, MD, Grazina Chatt, CT(ASCP), Eva Wojcik, MD, Güliz Barkan, MD. Pathology, Loyola University Medical Center, Maywood, Illinois Introduction: While effects of lubricant used during speculum examination have been well studied in conventional Pap tests, the effects on liquid-based
tests are less well characterized. Studies show, however, that potential exists for some water-based lubricants to interfere with ThinPrep (TP) Pap Tests. Our aim is to study the role of lubricant in unsatisfactory (unsat) TP Pap Tests and its impact on patient follow-up. Materials and Methods: All cases of unsat Pap tests due to low cellularity, too few squamous cells, lubricant, obscuring blood, or unspecified reasons were identified from a one year time period, and slides reviewed for presence of lubricant by a cytotechnologist and pathologist. Lubricant was considered present when a grainy, amorphous basophilic material was seen with associated clumping and obscuring of squamous cells. Electronic medical records were reviewed for clinical follow-up data, and chi squared test used for statistical analysis. Results: 212 unsat Pap Tests obtained by 53 clinicians were available for review. Upon review, lubricant was identified in 102(48%) of cases. Lubricant was identified significantly more often in cases reported as unsat due to low cellularity compared to those reported as unsat for all other reasons (p<0.001). Of patients with lubricant identified (mean age 49.6, range 18-83), 5 had prior history of endometrial cancer, 7 cervical cancer, 11 cervical dysplasia, and 3 abnormal vaginal bleeding. 32(31%) unsat Pap Tests with lubricant present were repeated, while 70 (69%) were never followed-up with a repeat Pap Test. Of the repeated Pap Tests, diagnoses were as follows: 21 negative, 8 unsatisfactory, and 3 ASCUS with negative HPV test. Identification of Lubricant in Unsatisfactory Pap Tests Reported Reason for Unsatisfactory Pap Test
Total Cases (n)
Lubricant Present on Review (n)
(%)
All Reasons Low Cellularity Obscuring Blood Lubricant Too Few Squamous Cells Unspecified
212 168 33 3 3 5
102 94 3 3 1 1
48% 56% 9% 100% 33% 20%
Conclusions: In our study, lubricant material was present in over half of cases diagnosed as unsat due to low cellularity, and presence of lubricant was significantly more likely in cases reported as unsat due to low cellularity than in cases reported as unsat due to other causes. Further, presence of lubricant was noted in the initial diagnosis in only 3 of these cases, suggesting that lubricant is likely being under-recognized and under-reported. By providing feedback to clinicians about lubricant in their reports, pathologists may help to reduce missed screening opportunities in these patients as many patients do not follow-up after unsat paps, reduce cost to the laboratory, hospital and clinician for repeated patient visits and Pap Tests, and more importantly, minimize inconvenience to the patient. 209 Detection of Malignancy in Body Fluid Cytology: A Comparison of the Hematology and the Cytology Laboratory Jaclyn Jerz, MD, Rachel Donohue, MD, Dina Mody, MD, Arthur Zieske, MD. Pathology and Genomic Medicine, The Methodist Hospital, Houston, Texas Introduction: Body fluid specimens submitted to hematology laboratories primarily for cell counting are also examined for the presence of malignancy. Many of these fluids are also submitted to cytology. We queried if it makes a difference whether a fluid is sent to the hematology or cytology laboratory. Materials and Methods: Quality assurance of the practice of identifying malignancy in body fluids by the hematology laboratory in our institution was assessed in a retrospective study. Cytologic or subsequent surgical pathologic diagnosis was considered the gold standard. Two hundred and ten body fluid specimens submitted to the hematology laboratory over two separate two month periods were evaluated in order to include all attending hematopathologists on that service. 95 of the specimens had concurrently or subsequently submitted specimens to cytopathology.
S114 Results: Thirteen of the 95 cases (14%) were diagnosed as malignant on cytologic evaluation. Three of these malignancies were detected by the hematology laboratory (3/13 Z 23% sensitivity); ten were not. There were no false-positive results of malignancy by the hematology laboratory. A hematopathologist consult had occurred in all three cases of malignancy that were concordant (3/3 Z 100%) and in 7 of the 10 cases that were discrepant (70%). The Romanowsky stained hematology slides for the 10 discrepant cases were retrospectively reviewed by an experienced hematopathologist and a senior cytopathologist. There was agreement that a definitive diagnosis of malignancy could not be made on the 10 cases based on the hematology lab cell count preparations. Since there was a concurrent cytology specimen or one submitted within a few days of the hematology laboratory examination, the discrepancies had no evident impact on patient care. However, this has led to reevaluation of body fluid submission policies to hematology and cytology and to reflex triage to cytology in selected cases. This quality improvement study is ongoing and a subsequent evaluation after the implementation of new policy and clinician education will be performed. Conclusions: 1) Body fluid specimens processed for optimal cell counting are not ideal for identification of malignancy. 2) Clinicians need to be educated on the limitations of identifying malignancy in specimens submitted and processed for cell counting. 3) In the current era of avoiding duplicate testing and the growing pressures on physicians to decrease testing overall, cytologic examination has the potential of being sacrificed in the interest of cost containment. This could have grave consequences for patient care. 210 Reprocessing Unsatisfactory ThinPrepÒ Pap Tests by a Modified SurePathÔ Method Yields Diagnostic Cells Melissa Randolph, BS, CT(ASCP), Harvey Cramer, MD, Howard Wu, MD, William Crabtree, PhD, SCT(ASCP). Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, Indiana Introduction: Over the past three years our laboratory has reflexively reprocessed Unsatisfactory ThinPrepÒ Pap Test samples by a lab validated method using a modified SurePathÔ reprocessing technique. This procedure was initiated to determine if residual unsatisfactory ThinPrepÒ samples could be salvaged via an alternative processing technique to obtain diagnostic cells that would have otherwise been discarded. Materials and Methods: All unsatisfactory ThinPrepÒ Pap tests encountered during the 3-year period from 2009 through 2011 were reprocessed using a modified SurePathÔ method validated in the Indiana University Health Pathology Laboratory. Initially, 4ml of fluid was aliquoted from the specimen vial to fulfill needs of HPV testing. The remaining fluid was submitted for reprocessing by the modified technique. The slides were stained with the ThinPrepÒ Imaging Protocol Ô stain to minimize inter-observer variance and then examined by manual review. The original ThinPrepÒ slide was submitted along with the reprocessed slide to the pathologists for sign-out. A note was entered in the report alerting the clinician to the extra effort of recovery when a case remained Unsatisfactory for interpretation. For cases that were satisfactory and found to yield an epithelial cell abnormality, the case interpretation was based on the examination of the cells from the combined preparations. In all, 1937 ThinPrepÒ Pap Tests were reprocessed and examined. The data was then compiled for analysis. Results: 1093 (56%) specimens were successfully converted to a satisfactory sample, with 624 specimens (57%) showing evidence of a transformation zone. HPV testing was performed on 405 (38%) specimens with a High-risk positivity rate of 12% (49). Epithelial cell abnormalities were identified in 116 (10.6%) specimens. ASCUS diagnoses comprised 79 (7.5%), LSIL was found in 21 (1.9%), HSIL was found in 11 (1.0%) and ASC-H was found in 5 (.4%) specimens. No invasive carcinomas were identified. Conclusions: The modified SurePathÔ processing was adept at handling almost all of the challenges that biological conditions (blood, lubricant,
Abstracts protein, etc.) present to liquid-based filter preparations. 1093 (56%) of unsatisfactory ThinPrepÒ pap tests were converted to a satisfactory state and 116 (10.6%) of the specimens presented the opportunity of an otherwise undetected abnormality to be diagnosed. The reflexive reprocessing results mirrored the percentage and distribution of HSIL, ASC-H and ASC abnormalities found in the patient population statistically existing in our laboratory. LSIL and AGC abnormalities were detected less frequently in this patient population. Additionally, with this method there is no need to validate a change in assay methods from the use of glacial acetic acid treatment. The laboratory is able to fulfill clinical co-testing requests. Pathologists have benefited from the reduction of caseload resulting from the reprocessing effort and are able to focus on pap tests needing review. Most importantly, patients benefitted by the identification of abnormal cells in their samples that would have otherwise been discarded and lost to analysis. 211 Comparison of Cell Block Preparation Using HistoGel and Plasma Thrombin Techniques Vanessa Benkovich, BS, Jackie Cuda, SCT(ASCP), Walid Khalbuss, MD, PhD, Liron Pantanowitz, MD, Alka Palekar, MD, Sara Monaco, MD. Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Introduction: Cell blocks are a useful adjunct tool available for the preparation and evaluation of specimens in aspiration and exfoliative cytology. Cell blocks are advantageous in that they show tissue architecture and can provide material for ancillary testing (e.g. immunocytochemistry and molecular studies). Our goal was to assess and compare the preparation of cell blocks in our laboratory using a variety of different methods. Materials and Methods: Ten fluid specimens (8 pleural, 2 peritoneal) were utilized to prepare cell blocks in 6 different ways: 5 different methods using HistoGel (Thermo Scientific Richard-Allan ScientificHistoGel; Kalamazoo, MI) and 1 using plasma thrombin (PT) technique. HistoGel cell pellet preparations involved lifting (HLIFT), stirring (HSTIR), or vortexing (HVORTEX) the pellet, in addition to letting the gel settle undisturbed (HSETTLE) and vortexing with refrigeration (HVORTEXF). Four cytopathologists blindly evaluated H&E sections of the 6 cell blocks from 10 specimens, and scored them on a scale of 1 (suboptimal, worst) to 5 (optimal, best) evaluating cellularity, cell distribution, morphology, background, pellet size, and overall quality. Averages were then obtained and evaluated to compare satisfaction with each of the preparation methods. Results: Based on the overall rating, the PT technique scored the highest in 8 of 10 (80%) specimens. Of the HistoGel preparatory techniques, stirring and vortexing received the highest ratings. In general, the PT technique received higher scores than HistoGel for cellularity, morphology, cell distribution, and pellet size in samples of high and low cellularity. Table 1 shows the overall average score for each preparation method for the 10 samples. Table 1 Comparison of Overall Average Score for Cell block preparation methods in 10 fluid specimens Specimen # 1 2 3 4 5 6 7 8 9 10
PT
HLIFT
HSTIR
HSETTLE
HVORTEX
HVORTEXF
3.2 4.9 3.8 4.0 3.5 4.7 4.3 2.9 3.8 2.5
1.7 3.1 2.3 3.2 2.7 3.9 3.6 2.2 2.9 4.0
2.0 3.9 3.4 3.2 2.1 4.2 3.7 2.5 3.3 2.4
1.6 3.3 1.6 3.0 2.3 3.4 3.0 2.5 2.1 2.8
1.9 3.9 2.4 2.4 1.8 4.0 4.1 1.3 3.8 2.4
1.8 4.2 1.7 3.3 2.2 4.1 4.1 2.4 4.2 2.3
Legend: Plasma Thrombin (PT), HistoGel: Lifting (HLIFT), HistoGel: Stirring (HSTIR), HistoGel: Settle (HSETTLE), HistoGel: Vortexing (HVORTEX), HistoGel: Vortexing with refrigeration according to package insert (HVORTEXF)
Conclusions: Based on these data, the PT cell block method showed superior quality compared to cell blocks prepared in a variety of other ways