Proficiency Timeline for Pathologist-Performed Ultrasound-Guided Fine Needle Aspiration Biopsy (USFNAB) in a Recently Established Service: A Personal Experience

Abstracts 2 On-Line Education in Cytotechnology-A Pilot Study Amber Donnelly, PhD, MPH, SCT(ASCP), Maheswari Mukherjee, PhD, MS, CT(ASCP), Elizabeth Lyden, MS, Stanley Radio, MD University of Nebraska Medical Center, Lincoln, Nebraska Introduction: Our cytotechnology program has received requests for an online program, requiring little to no training on site. The purpose of this study is to demonstrate that on-line education with virtual microscopy (VM) achieves similar screening and interpretation skills as traditional teaching methods using light microscopy (LM). Materials and Methods: The pilot phase was conducted using the female genital tract (FGT) and respiratory tract (RT) courses. The students in the program were divided into two groups; control and experimental. The experimental group replaced LM with VM for the entirety of the two courses, while the control group utilized traditional teaching methods. At the end of the two courses, the experimental group was given a tutorial on how to use a microscope and was also given glass slide examinations for both courses. Results: The mean of the screening quizzes and exams of the control group for the FGT course was 92.5 with a standard deviation (SD) of 3.5; the mean for the experimental group was 86.8 with a SD of 2.0. For the RT course, the control group had a mean of 96 for their screening exams while the experimental group’s was 85.3; the SDs were 6.4 and 4.5 respectively. The glass slide examinations (FGT Mean Z 98, RT Mean Z 95.3) given to the experimental group at the end of the pilot study demonstrated their ability to apply screening and interpretation skill learned from VM to LM. Conclusion: The study concludes that screening and interpretation skills of the control and experimental groups in this study were similar. It appears possible to train future students using VM as the sole method of teaching. The study will be extended to another cohort of students using the entire curriculum to further demonstrate the soundness of these results.

S7 “driving the slide” for adequacy assessment. The MagnifiÔ had the best ease of use by staff. Conclusion: Validation protocols for the utility of FaceTime, in the setting of ROSE FNA, assures real-time connectivity of cytotechnologists with cytopathologists in an effort to provide increased diagnostic feedback on difficult cases. FaceTime allows access to an expert opinion for assurance of an onsite assessment and help with triaging the case for ancillary testing. 4 Proficiency Timeline for Pathologist-Performed Ultrasound-Guided Fine Needle Aspiration Biopsy (USFNAB) in a Recently Established Service: A Personal Experience Adele Kraft, MD, Mary Clark, BA, MS, Ed, CT(ASCP), Celeste Powers, MD, PhD Virginia Commonwealth University Health System, Richmond, Virginia Introduction: As pathologists performing USFNAB we are frequently asked: how much time does it take to become proficient? This study presents the experience of a pathologist gaining proficiency in USFNAB, working in a recently established USFNAB service at an academic institution, aiming for an unsatisfactory rate <4%. Learning tools included a practical course by a major Pathology society, independent practice with “phantoms”, observation, ultrasound simulator program, DVDs and books. Materials and Methods: Utilizing the Pathology Department’s electronic database a retrospective review of all the USFNAB performed by pathologist AOK was performed. A timeline was established beginning with the first procedure performed in 09/06/2012 up to the 300th consecutive procedure in 04/06/2015. The timeline was separated into six consecutive blocks of 50 procedures. For each USFNAB the following were recorded: professional assisting the procedure; diagnostic vs. unsatisfactory result; body site. Results: Presented in Table 1 and Table 2.

3 FaceTime Validation Studies in an Academic Medical Center: Applicable Considerations for Patient Safety, IT Security and Workflow Optimization Kristen Bifalco, CT(ASCP), Matthew Zarka, MD, Amy Wendel Spiczka, MS, SCT, MB, HTL(ASCP)CM, Kimberly Rose-Fuson, CT(ASCP), Amy Beckwith DeMaagd, CT(ASCP), Karyn Hallberg Wallace, CT(ASCP), Longwen Chen, MD, PhD Mayo Clinic Arizona, Scottsdale, Arizona Introduction: Validation of FaceTime utilization to support rapid-on site evaluation (ROSE) of EUS and EBUS FNA services assures quality outcomes for patients through cytotechnologists (CT) to engage cytopathologists’ (CP) diagnostic reviews real-time. Use of dynamic cytotelepathology also allows for triaging of FNA specimens. FaceTime in this validation or clinical setting is not intended for use of primary interpretation or final diagnosis. Materials and Methods: Validation and implementation of FaceTime on the Apple iPhone 5 device with MagnifiÔ phone adapter was performed in 3 phases. Phase 1: -Ethanol-fixed test cases from numerous sites and of varying degrees of normal through several malignant subtypes were prepared from gross specimens with a needle aspirate. These ‘test cases’ were utilized to validate the use of the devices and coordinate effective handoffs between the CT and CP in a real-time, image-driven experience. Phase 2: Assessment of 25 live cases was supported in the validation proceedings through having a CT and team lead-CT develope proposed workflows in the clinical domains while contacting a cytopathologist by FaceTime. Phase 3: The final validation phase, prior to implementation, incorporated the workflow and competencies for all CT and CP users. Results: Phase 1 validation of MagnifiÔ and SnapZoom phone adapters were tested to contact the CP. CT practiced communicating with CP and

Table 1

Table 2

Timeline for USFNA cases

Case distribution by site

S8

Abstracts

Conclusion: A definite learning curve was observed: as experience was gained there was a steady decrease in the unsatisfactory rate. The <4% target was reached after 250 procedures. Assistance by either ultrasound technologist or cytotechnologists specially trained seems equivalent in relation to the final unsatisfactory rate. Even though the study pathologist had extensive experience in palpation-guided FNA, USFNA presents particular technical challenges especially in very small targets, obese patients and/or hard to reach nodules close to major vessels. Good knowledge of sonographic anatomy, constant practice with phantoms, continuing medical education (CME) and direct supervision by an experienced physician can help decrease the numbers to achieve the desired target. Monitoring the unsatisfactory rate for each individual pathologist and providing CME and direct observation as needed may help in speeding the proficiency process. 5 HPV/Cytology Co-Collection Implementation: Lessons Learned Narjes Mousavi-Nasab, BS, CT(ASCP), Jorge Almenara, PhD, Celeste Powers, MD, PhD, Le Tran, MT(ASCP), Betty Forbes, PhD, (ABMM), Christopher Doern, PhD, Adele Kraft, MD Virginia Commonwealth University Health System, Richmond, Virginia Introduction: Recent studies have shown that specimens collected in BD SurePath preservative fluid for HPV testing can yield false negative results. This study aims to report the steps taken and the challenges encountered in the process of implementing co-collection of SurePath for Pap test with a concurrent sample dedicated for HPV testing. Materials and Methods: After extensive evaluation by representatives from Cytopathology, Microbiology and Gynecology it was resolved that SurePath remained the collection device of choice for Pap test while a separate collection device (Qiagen Specimen Transfer Medium (STM) would be used to concurrently collect the specimen for HPV testing. Actions for implementation spanning a three month period are listed below: 1. Working with IT to change the ordering in the hospital software 2. Development of collection material packages and labels. 3. Development of an educational brochure. 4. Intradepartmental informational sessions 5. Educational sessions by representatives from Cytopathology and Microbiology with all the clinics involved in collection. 6. Distribution of collection packages. Results: Extensive education of clinical providers who collect Pap test was required. The main focus was on communicating: 1. 2. 3. 4. 5.

Reason for change. Patient and physician benefit. Introduction of the STM collection device Rationale for sending specimens in separate bags. Collection technique: can same brush be utilized?

The change to co-collection encountered minor setbacks with few providers forgetting to collect two specimens, mislabeling or delivery to incorrect location. Conclusion: Successfully achieving a smooth transition or the implementation of co-collection was accomplished by educating both laboratory staff and providers over a four month period. 6 Turning the Rapidly Changed Cytology World Around by Cross Training Cytotechnologists in More Marketable Skills Narjes Mousavi-Nasab, BS, CT(ASCP), Mary Clark, BA, MS, Ed, CT(ASCP), Jorge Almenara, PhD, Caitlin Simmons, CT(ASCP), Adele Kraft, MD Virginia Commonwealth University Health System, Richmond, Virginia

Introduction: The decline in Pap tests has led to the search for new roles for Cytotechnologists (CTs). The goal of this study is to present the successful experience of cross training in “in situ” hybridization techniques performed by CTs at our institution, their role in validation and in clinical test performance. Material and Methods: One week of intensive training for RISHTM probe technology was undertaken by the Cytotechnology Supervisor at the proprietary company training center. Two other CTs underwent inhouse training by a Field Applications Specialist. For initial validation twenty formalin-fixed paraffin-embedded (FFPE) tissues with documented positive latent membrane protein (EBV-LMP, clone CS.1-4, Dako, Carpinteria CA) by immunohistochemistry were utilized. The CTs performed hybridization utilizing the RISHTM Epstein-Barr Encoded RNA (EBER) Probe (Biocare, Concord, CA). Slides were evaluated by the CTs for quality of the stain and cellular content prior to the pathologist final interpretation. The CTs determined when adjustments in reagent dilution and incubation times were needed in order to reach ideal target versus background staining and made the alterations accordingly, recording all the steps, communicating with the proprietary company technical support, under the supervision of the Technical Director of Anatomic Pathology. Results: 100% correlation was achieved between the IHC and RISH HRP Epstein-Barr virus detection. Conclusion: This study demonstrates how Cytotechnologist’s skills such as knowledge of morphology, attention to detail and analytical thinking can be successfully applied in other areas of the laboratory such as RISH in situ hybridization with minimal training.

7 Cytotechnologists Accurately Pre-screen Prostate Cores on Traditional Glass Slides and Digital Whole-Slide Images Louis Vaickus, MD, Kristine Cornejo, MD, Brenda Sweeney, SCT(ASCP)MB, Mary Rego, BA, CT(ASCP), Heather Smith, BS, CT(ASCP)MBCM, Nicholas Jones, David Wilbur, MD Massachusetts General Hospital, Boston, Massachusetts Introduction: Cytotechnologists have a unique training and skill set designed to identify abnormalities often in a low prevalence environment. In order to test whether this skill could be extended to histopathologic specimens, the present study investigated the cytotechnologists’ ability to screen prostate needle core biopsies. In addition, the use of digital whole slide imaging for this task could make the physical location of the technologist inconsequential to the location of the pathologist. Materials and Methods: Two cytotechnologists were given 3 one hour introductory training sessions on prostate histopathology and additional sessions on the use of whole slide image viewing and interpretation. Thirty full sets of prostate biopsies digitized into whole slide images. The cytotechnologists screened 15 cases on glass slides and 15 cases digitally and rendered an interpretation of negative or atypical for each case and these interpretations were compared to the final diagnosis from the original surgical pathology report. Results: The cytotechnologists showed sensitivity and specificity of 84% and 81%, respectively, for the detection of prostate adenocarcinoma on prostate core biopsies. They performed slightly better (although not significantly, p Z 0.29) on glass slides as compared to digital whole slide images (Table 1) Conclusion: In this very preliminary foray into the screening of histopathologic specimens, cytotechnologists showed reasonably good sensitivity and specificity for the detection of adenocarcinoma in prostate core biopsies with minimal histopathological training. That the technologists performed as well as they did with only 3 hours of total surgical pathology instruction is highly encouraging. There were differences noted between interpretations rendered on glass slides versus