1-1 Cytopathology Personnel, Procedures and Policies

Lectures

• Lecture: Intro to Cytopathology - Dr. Pitman
• Lecture: Overview of liquid based methods by E. Brachtel MD

Cytopathology Laboratory

• Location: Warren 125 (6-3980) – Main Cytology Office: supervisor’s office, cytotechnologists’ stations, cytopathology fellow desks (4-1422), secretaries and multi-headed microscope
• Warren 113 (4-1424) – Cytology Specimen Preparation Room: specimen drop off
• Wang 270-FNA exam room (4-1077)
• Wang 290- FNA waiting room on ACC-2

• Staff:

• • Director of Cytopathology (Technical Supervisor) - Martha B. Pitman, MD (Warren 105C)
  • Director of Fine Needle Aspiration Service: Amy Ly, MD (Warren 105F)
  • Technical Director (General Supervisor)- Brenda Sweeney, MS, SCT(ASCP)MB
  • Technical Specialist – Ron Arpin, MS, SCT(ASCP)

• Cytopathologists:

• • W. Stephen Black-Schaffer M.D
  • Elena Brachtel, M.D.
  • Ivan Chebib, MD
  • William Faquin M.D.
  • Joseph Misdraji M.D.
  • Rosemary Tambouret M.D.
  • David Wilbur, MD

• Cytotechnologists - Peter Brown, Heather Grant, Diane Kuebler, Marilyn Nutter, Mary Pinheiro-Rego, Lisa Ring, and Caitlin Eno
• CLA Secretaries – Bernadette Femino and Diane White
• Lab Preparatory Technologists - Ernest Li, Shirley

Hours of Operation:

• The Cytopathology Laboratory is open Monday through Friday:
  • For reports and information: 8:30 a.m. - 5:00 p.m.
  • For specimen preparation: 7:30 a.m. – 5:00 p.m.

• After Hours Policy

• • Fine Needle Aspirations are not performed by the pathologist service after hours or on weekends under any circumstances.
  • Rarely an urgent cytology specimen requires a rapid evaluation during off-hours. This is the case only if the rapid interpretation will affect current patient care. Once the chief resident establishes the medical necessity of the rapid interpretation, the cytopathologist should be called.
  • The chief resident has a list of the cytopathology attendings' home telephone numbers. Since there is no on-call rotation for such circumstances, call the attendings in the listed order until one is contacted. The cytopathology staff member will then contact the cytotechnologist to prepare the specimen if necessary.
  • Certain cytology specimens such as CSF and pleural effusions are often divided for evaluation by various clinical labs, including cytology. The clinical pathology labs are staffed 24 hours a day and often result such specimens before the cytology lab. If a rush result is requested when the cytology lab is not open, the resident can check if the clinical lab result is available. An example is a spinal tap in a patient with suspected meningeal carcinomatosis. The hematology analysis is often ready first.
    
    

Services Offered

• Diagnostic interpretation of cytology specimens:

• • All cases are screened by cytotechnologists. Except for negative cervical smears that can be directly signed out by the cytotechnologist, all cases are passed on to the cytopathologist for interpretation, diagnosis and final sign out

• Fine needle aspiration biopsy (FNAB) service:

• • The FNAB is a minimally invasive technique to cytologically sample mass lesions. FNABs are performed by cytopathologists at the request of clinicians on patients who have a superficial mass. Pathologists most often use palpation to guide the needle, but have access to ultrasound to guide the FNA for thyroid FNAs, and for more ill-defined masses or for those inadequately productive by palpation guidance. Masses in visceral organs must be sampled by radiologists under imaging guidance. The service is offered Monday through Friday from 9 a.m. to 4 p.m. by appointment (in advance or same day space provided) with the cytopathology secretary (617-726-3980). The procedure is usually performed in the FNAB Clinic, Wang 270. If necessary, the FNAB can be performed in the clinician’s office or in the OR. All in-patient FNABs are performed in their room.

• Rapid Evaluation and Interpretation (Rapids):

• • The procedure is akin to the frozen section for surgical pathology. Rapids may be requested by the ordering physician on any specimen sent to the cytology lab. Most often however Rapid On-Site Evaluations (ROSE) are performed. Currently, the services requesting ROSE at MGH include Thoracic Interventional Radiology (Blake 2), Gastroenterology (endoscopic ultrasound (EUS) FNA (Blake 4), Pulmonologist or Thoracic Surgeon performed endobronchial ultrasound guided (EBUS) FNA (Blake 3 Frozen Section Lab) and Pathologist performed FNA (Wang 2). See below for further details.

Critical Values for Cytopathology

1. The pathologist (or nominated designee) will transmit a result urgently to the attending physician or another licensed caregiver who can take action on the results, ideally by telephone, under the following general circumstances:

• An unexpected diagnosis of malignancy
• Any other clinically significant and time-sensitive finding which was unexpected or unsuspected (as determined by clinical information provided)
• Any significant discrepancy between permanent section and frozen section diagnosis/ interpretation
• An addendum or an amendment report, which provides information significantly different from that rendered in the original report

2. The following case types constitute a critical value in cytology:

• Bacteria or fungi in CSF cytology in immunocompromised or immunocompetent patients
• Pneumocystis, fungi or viral cytopathic changes in bronchoalveolar lavage (BAL), bronchial washing or brush cytology specimens in immunocompromised or immunocompetent patients
• Acid-fast bacilli in immunocompromised or immunocompetent patients
• Fungi in any FNA from immunocompromised patients
• Herpes in Pap smears of near term pregnant

• To document notification, insert Coded Comment: “NOTIFY”[F8}
• To flag the case as a critical value case, check the
• Retrieval Flag: CVR [critical value report]
• GYN cases: staff/reflex tab
• Non-GYN case: QA tab

Cytology Specimens

Specimen types:

Gynecologic (Pap smears):

• Liquid-based preparations (cervical sample dispersed immediately in alcohol).
  • SurePath (BD Tripath)
  • ThinPrep (Hologic Cytyc)
• Conventional smears (cervical scrap/brush directly applied to glass slide)

Non-gynecologic:

• Fluids: included in this category are:
  • Body fluids containing cells exfoliated in situ (urine, pleural effusion, ascitic fluid, CSF, sputum, cyst fluids),
  • Fluids that were created by washing an epithelial surface with saline and re-aspirating the washed fluid to recover the sloughed cells (pelvic washing, bronchial washing, bronchial-alveolar lavage (BAL), gastrointestinal washing)
  • Needle rinses from fine needle aspiration procedures
  • Rinses from brush specimens.
• Brushings: An epithelial surface can be brushed during a procedure (usually bronchoscopy or endoscopy of the gastrointestinal or pancreatobiliary tracts) and the material on the brush is either smeared onto the glass slide and fixed or the brush is rinsed into CytoRich Red for LBC processing immediately fixed in a jar of 95% ethanol.
• Fine needle core biopsies: During radiologist-guided FNABs using imaging, the radiologist may elect to also obtain a thin core biopsy which is fixed immediately in formalin and processed as paraffin-embedded biopsy. Since the biopsy is often small, if additional studies are anticipated at the time of processing, a request for blanks on glue may be made by writing CYT X on the surgical pathology requisition sheet where X is the number of blanks desired for ancillary studies (e.g. CYT 4, CYT6, etc).
• Touch preps: A cytology slide can be made by gently touching a surgical biopsy specimen to a glass slide followed by rapid fixation of the slide for staining. This commonly performed by the radiologists during interventional procedures. Touch preps can also be made in the frozen section lab to enhance evaluation of intraoperative tissue analysis.
• Cell blocks: The residua of fluid specimens can be centrifuged after the initial cytology preparation is made in order to harvest the sediment.
  
  

Specimen Collection

Cytology test orders are only accepted from individuals authorized to do so in accordance with law and regulation.

• Gyn specimens (Pap smears):

• • Conventional smears are fixed in 95% alcohol in a jar supplied by the cytology lab. For liquid based preparations, the sample (taken by broom, brush or spatula) is placed in the appropriate container, 24% ethanol for SurePath (sampling device remains in vial) and 50% methanol for ThinPrep (TP). The TP vial for gyn specimens has a pink label. Include last menstrual period and information on previous abnormal reports, treatments or biopsies on the requisition when available.
  • Missing clinical information may be obtained by Cytopathology personnel from CAS to help resolve cytological evaluations when necessary.

• Non-gyn specimens:

• • All specimens smeared on slides (brushings, FNABs, touch preps) should be fixed immediately in 95% ethanol in jars provided by the cytology lab and delivered to Warren 113 as soon as possible. To prevent slides within the jar from sticking together, place a small paper clip on alternating slides.
  • All non-smear specimens that are bathed in their own fluid (e.g., urines, body fluids, sputum, CSF, BAL’s) should be fresh and delivered to the laboratory as soon as possible, preferably within one hour. No 24-hour collections are acceptable. Saline needle rinses should also be promptly delivered to the cytology lab. Needle rinses placed in fixative (CytoRich Red or formalin) can tolerate a slight delay.
  • All specimens must be labeled with the patient's name and unit number and must be accompanied by a properly completed Cytopathology requisition (form #10299). All pertinent information must be included to ensure accurate cytological evaluation and comply with federal regulations. Missing clinical information may be obtained by Cytopathology personnel from CAS to help resolve cytological evaluations when necessary.

Specimen Delivery

• Between 7:30 a.m. and 5:00 p.m. (Monday through Friday), specimens should be delivered to the cytopreparatory laboratory area (Warren 113). When the laboratory is closed, specimens should be taken to the Core lab on Gray 5 between the hours of 5 p.m.-7:30 a.m. Monday-Friday and on weekends/holidays.
• Verbal Orders:
  • MGH Department of Pathology Verbal Add on Test Request Form must be used for all verbal orders and is available on the pathology intranet at: http://intranet.massgeneral.org/pathology/documents/Dept%20ADD%20on%20Form%20%20FINAL%20Oct.29%2703.pdf

Specimen Rejection Policy

Specimens received in the Cytopathology Laboratory having identification information that cannot be verified will not be processed. Two patient identifiers must be provided and verified as correct before laboratory specimens will be processed or tested. Both container or slides and requisition must be labeled. The labels must contain the patient’s full name and/or medical record number and/or date of birth. Identifiers must match one another. Specimens that are not readily replaced and have identification discrepancies will be processed upon completion of a Specimen Release form and corrected requisition by an individual authorized to take such responsibility. (See cytology manual for complete procedure).

Rapid on site evaluation and interpretation

• Rapid interpretations are performed on most FNABs performed by the pathologist or other physicians (radiologist, gastroenterologist, pulmonologist, surgeon) in order to guide the procedure. The rapid is intended to assess if the specimen is representative, to determine the need for additional passes and to correctly triage the material for special studies if need be (flow cytometry, cultures, electron microscopy or a request for core biopsy by the radiologist). A definitive diagnosis is not necessary at the time of rapid interpretation although this may be possible in many cases.

• For radiologically obtained FNABs, a cytotechnologist selects one smear per pass, stains the smear with H&E and evaluates the smear. When the tech estimates that the smear is representative, the pathologist is called to give the rapid interpretation.

• Rapid interpretations of previously submitted specimens or specimens obtained by the clinician will be performed only if the rapid interpretation will affect current patient care.

• Please send ALL specimens from the procedure for each patient to cytology at the same time to avoid delays in processing.

FNA Tissue Triage For Radiologically Guided CT/US Guided Biopsies

Perform FNA first

• Two passes- 4 smears placed in alcohol
• If there are “worms” of tissue or a clot on the slide, use a needle tip to transfer these to small formalin tubs (Peoplesoft #160435 for ordering) or CytoRich Red preservative (from Cytology lab). Do not attempt to smear the “worms” or clots.
• Rinse the needle in CytoRich Red preservative.

2. If lymphoma suspected or tissue needed for culture, rinse needle in saline from a dedicated FNA.

3. If lesion is not amenable for core biopsy OR contains clots from FNA, perform a dedicated FNA explicitly to obtain additional tissue for cell block; rinse in CytoRich Red and request that a cellblock be made.

4. Biopsy for molecular testing must indicate this need on the Histology requisition form. Tissue to be submitted with Cytology Requisition:

• Direct smears
• Washings
• Brushings
• Needle rinsings in CytoRich Red if no clots in container
• Saline rinse for flow cytometry. Contact flow cytometry for a supply of RPMI preservative (6-8487) if there is potential for delay in specimen processing, e.g. a late Friday afternoon procedure.

5. For FNABs performed by the pathologist, slides are stained according to the individual preference of the cytopathologist (H&E, modified Pap stain, toluidine blue or WG).

Perform core biopsy second

• Place core biopsy directly into formalin tub or transfer to formalin before submitting to cytology lab. Do not add cores to CytoRich Red preservative.

2. Tissue to be submitted with Histology Requisition (provide clinical information, especially if molecular studies desired):

• Core biopsy in formalin
• Needle rinsings for cellblock if clots placed in solution

3. All tissue with cytology can be sent to the cytology lab for processing with their respective requisitions. Cores only without smears should be submitted to Blake 3 for accessioning.
4. Tissue for culture is sent directly to the microbiology lab.

Tissue Triage for EBUS Procedures

Brushing

• Cut the end off of the bronchial brush and place in a tube of CytoRich Red solution, also provided by the cytology lab
• If a rapid interpretation is needed of the brushing specimen, make one direct smear on a non-frosted slide and immediately place the slide in a jar of 95% ethanol which is provided by the cytology lab (call 6-3980 for supplies).

Bronchial wash and lavage

• Collect washing/lavage fluid and submit fresh to the cytology lab.

EBUS-FNAB (do not need rapid interpretation if doing a concurrent frozen section of core biopsy)

• Express the material near the label end of a non-frosted slide, smear and place in 95% ethanol.
• If there are “worms” of tissue or a clot on the slide, use a needle tip to transfer these to small formalin tubs (Peoplesoft #160435 for ordering). If formalin is not available, these samples can be place in CytoRich Red preservative solution.
• Do not attempt to smear the “worms” or clots.
• Perform a dedicated FNA explicitly to obtain additional tissue for cell block; Express tissue directly into formalin container.
• If lymphoma is suspected, please do a dedicated FNA to obtain tissue for flow cytometry. This tissue should be placed in sterile saline or RPMI preservative (contact flow cytometry for a supply, 6-8487) if there is potential for delay in specimen processing, e.g. a late Friday afternoon procedure.
• If there is a question of infection, please obtain a sample to be sent directly to microbiology.

Core biopsy should be placed in a separate formalin tub. The two formalin tubs are submitted with one histology requisition with two specimens: A. “cellblock” and B. “core”

• Biopsy for molecular testing must indicate this need on the Histology requisition form.