Cytopathology
Duration: Three months
Rotation Director(s): Shagufta Khan, MD
Faculty/ Instructor(s):
Fred Lucas, MD
Jiang Wang, MD, PhD
Description of Rotation
The goals of this rotation are to enable the residents to become proficient in assessing cytopathology specimens, to arrive at a correct diagnosis and to appreciate the impact of this service on patient care.
Rotation Objective
- Become familiar with slide preparation techniques of both conventional smear and liquid-based preparations and proper evaluation of Pap stain characteristics. The resident should be able to evaluate and troubleshoot slide preparations and stains.
- Develop diagnostic skills to distinguish, compare and contrast the following: normal epithelium, infectious/inflammatory entities, benign proliferative reactions, dysplasia and malignancy.
- Learn about the limitations of cytological diagnoses. Be able to communicate the proper techniques for cytopathology specimen collection to clinicians. Understand quality indicators and be able to communicate their significance and rationale to clinicians.
- Develop good differential diagnostic skills for gynecologic and non-gyn cytopathology. Be able to examine any gynecologic cytopathology specimen and properly classify it by The Bethesda System 2001. Be able to properly classify FNA (fine needle aspiration) biopsies and exfoliative non-gynecologic cytopathology specimens using the current laboratory system. Be able to recommend appropriate clinical follow-up for each specimen.
- Perform FNAs and master the cytological features of Diff-Quick and Pap stains.
- Process bronchioalveolar lavage specimens and interpret the findings in accordance with the established protocol.
- Develop skills to design and execute ancillary studies in conjunction with cytology findings (special stain, immunohistochemistry, and electron microscopy).
- Become familiar with federal regulations which apply to cytopathology. Become familiar with quality assurance programs in cytopathology.
- Communicate and interact with cytopathology professionals to enhance the learning experience.
- Attend the weekly divisional meetings.
- Present a 15-minute educational session at least once.
- Do a small project, if time allows, leading to a presentation and/or publication in collaboration with the cytopathology division faculty and staff.
Level of Training
First Month: Gynecologic Cytology Section
Reading assignments
- The Bethesda system for reporting cervical cytology. Diane Solomon, Ritu Nayar
- Cytology Diagnostic Principles and Clinical Correlates (Chapter 1). Edmund Cibas, Barbara Ducatman
- Practical Principles of Cytopathology. Revised by Richard M. DeMay
- The Art & Science of Cytopathology. Richard M. DeMay
Activities
Glass slide study sets - the resident will study each unit of glass slides in conjunction with the appropriate reading assignment according to the following schedule:
- Week 1 and 2: Cytopreparation including processing of ThinPrep and conventional slides, pap staining, use of imager
- Molecular testing – HPV/CTNG.
- Week 3: Normal cytology, inflammatory and reactive cytology, benign proliferative cytology, ASCUS, dysplasia, Carcinoma in-situ, Glandular lesions including endocervical and endometrial neoplasia.
- Week 4: invasive malignancies and extra-uterine malignancies, QC/QA and study set maintenance.
After the first week, the resident is expected to perform initial screening of five to 10 gynecologic smears per day. Additionally, he/she will evaluate three to eight dotted “unknowns” daily. The resident will document his/her diagnoses using the Bethesda classification. In the afternoon, the resident and the cytotechnologist will review the cases at the multi-headed scope with a critique of the resident’s written diagnoses. A summary of this activity will be included in the month-end evaluation.
Quality Control/Quality Assurance Program
- Review the QC/QA methods used at Tri-State in conjunction with requirements from the College of American Pathologists.
- Perform cytology-histology correlations on subset of cases from prior month.
- Calculate QC statistics for prior month’s cases.
Prepare new cases for inclusion in teaching study set.
Evaluation
The resident will be evaluated based on the following:
- Pre-test – this will consist of a 10-slide timed examination taken at the beginning of the first day of the rotation.
- Post-test – this will consist of an additional 10-slide timed examination taken at the beginning of the last day of the rotation.
- Compiled results of diagnostic accuracy from daily review of primary and secondary screened slides.
- Completion of QC/QA activities and study set additions as assigned above (C3 and C4).
- Professionalism, including interactions with faculty, clinicians and support staff.
The resident will complete an evaluation form of the rotation, faculty and support staff.
Second Month: Non-Gyn Cytopathology
Reading assignments: The resident will study each unit of glass slides in conjunction with the corresponding reading assignment according to the following schedule:
- Week 1 – Respiratory
- Week 2 – Respiratory and breast aspiration cytology
- Week 3 – GI tract and liver aspiration cytology
- Week 4 – Effusion and head and neck aspiration cytology
At the end of the second week, the trainee will review current non-gyn cytology as unknowns. Cytopathology faculty will examine these cases at the multiheaded microscope during the sign-out. The written resident diagnosis will be critiqued. This will generate comments concerning performance on unknowns as well as verify comprehension of the appropriate reading assignments.
The resident is mandated to attend all the didactic 8 a.m. sessions, and he or she is excused from any assignment during this period.
The resident is mandated to attend the colposcopy conferences. A sign-in sheet will monitor attendance.
By week 3, the resident will run the colposcopy conference.
The resident is expected to keep a daily log of his or her activities/progress
Fine Needle Aspiration Biopsy:
- Autopsy and surgical pathology specimens (FNAs): Prior to direct clinical interactions, the resident will be instructed how to perform FNAs on an inanimate object (e.g., an orange) and how to smear the material. He or she will perform percutaneous FNAs on selected autopsies to include: thyroid, lymph nodes, liver and breast. Additional FNAs will be performed on dissected organs and masses to include liver, lung, adrenals, pancreas, kidney and prostate.
- When available, the resident will initially observe the FNA techniques in the clinical setting, and then be permitted to procure the aspirate under direct supervision. Each case the resident participates in will be diagnostically worked up by the resident prior to final sign-out.
- The resident must accompany the cytotechnologist or cytopathologist on all FNAs and procedures.
- The resident is expected to keep a log of all FNAs and procedures that he or she participated in.
The resident will complete the evaluation form of the rotation, the faculty and the staff.
At the end of the second month, the trainee will be evaluated by:
- End of rotation written and unknown glass slide test.
- Assessing the trainee daily log
- Comprehension of reading assignments.
Third Month: Non-Gyn Cytopathology
Reading assignments: The resident will study each unit of glass slides in conjunction with the appropriate reading assignment according to the following schedule:
- Week 1 – Head and neck aspiration cytology, CSF cytology
- Week 2 – Urinary tract and renal aspiration cytology
- Week 3 – Lymph node aspiration cytology and miscellaneous aspiration cytology.
- Week 4 – Review
The resident is mandated to attend all the didactic 8 a.m. sessions and he or she is excused from any assignment during this period.
The resident is mandated to pre-review cases to be presented at the weekly Colposcopy Conference and attend this conference. Competent and comfortable residents, selected by the faculty, will lead the weekly Colposcopy Conference. The resident is to review cases for, and participate in leading these conferences. A sign-in sheet will be kept to monitor the attendance.
The resident must accompany the cytotechnologist or the cytopathologist on all FNAs and procedures. He or she is expected to procure as many aspirates as possible by the end of the rotation. Procurement numbers are based upon patient availability at time of rotation.
The resident will work all FNAs and document the diagnosis. The cytopathologist will critique the trainee’s diagnosis during the final sign-out at the multiheaded microscope.
The resident is expected to keep a daily log of his or her activities/progress.
The resident is expected to keep a log of all FNAs and procedures that he or she participated in.
The resident will complete the evaluation forms of the rotation, the faculty and the staff.
At the end of the third month the trainee will be evaluated by:
- End of rotation oral and written presentation at a.m. residents’ conference. (PowerPoint presentation with thorough investigation into the topic.)
- Assessing the trainee daily log.
- Comprehension of reading assignment
- End of rotation written and unknown glass slide test.
Daily responsibilities
- To review all study materials including reference books and glass slide study packets as well as Kodachrome exercises.
- To complete all gynecological and non-gynecologic glass slide unknown study exercises
- To attend monthly ASC teleconferences.
Evaluation
- End of rotation oral presentation.
- Assessing the trainee daily log.
- Comprehension of reading assignment
- End of rotation written and unknown glass slides.