October 2011
Feature Story

Holly Strawbridge

It’s a time-intensive procedure, one for which there is a lot of downtime for the pathologist: a staging endobronchial ultrasound in which the clinician aspirates multiple lymph node locations. Thanks to a telecytology program, Meenakshi Singh, MD, and colleagues, of Stony Brook University Medical Center in New York, have done away with the downtime. When they are on hand now for a staging EBUS, or any immediate evaluation of a fine-needle aspiration specimen, they remain in their offices, where they review in real time the images that a cytotechnologist sends from the bronchoscopy or interventional radiology suite.

“If I had sat through the entire procedure in the suite, it would have taken more than an hour,” she says of a recent EBUS procedure. “As it was, it probably took me five to 10 minutes,” says Dr. Singh, professor and vice chair of anatomic pathology at State University of New York at Stony Brook.

With demands on pathologists’ time having grown and still growing, there is a pressing need for efficiency. Telecytology, Dr. Singh says, saves pathologists the time spent waiting on the floor while the clinician collects samples and the cytotechnologist does the staining. “Multiply the savings by the number of cases you do, and you will see substantial results,” she says.

Dr. Singh came to Stony Brook in 2008 from the University of Colorado. One of her first projects was to analyze the activities of the anatomic pathology division, with an eye to improving efficiency through technology. Soon she and colleagues began to evaluate the use of voice recognition software in their surgical pathology practice, and eventually they fully implemented it. (See next month’s issue of the Archives of Pathology & Laboratory Medicine for the report.)

When Dr. Singh analyzed the cytology service, she noticed pathologists were spending more and more time on the immediate assessment of specimens from endoscopic and radiological procedures. “We had to find a way to do cytology in a more efficient manner. In addition to maximizing resources, I wanted to reduce waste, have more time to do patient care activities, and provide better quality patient care,” she says.

It was natural for Dr. Singh to look to digital technology to help cytopathologists evaluate fine-needle aspirations remotely. She’s a faculty member who is active in resident education (residents on the cytology rotation participate in the on-site work and the immediate evaluations using telecytology) and, as selective (surgical) pathology fellowship program director, she retains a file of digital images to use in teaching cytology. She has made many pathology images available free through two online atlases of breast and gynecologic pathology (www.hsc.stonybrook.edu/breast-atlas/ and www.hsc.stonybrook.edu/gyn-atlas/index.html).

After a review of literature, she chose a relatively inexpensive Web-based solution that uses a Nikon Digital Sight DS-L2 camera attached to a regular Nikon Eclipse microscope. Images are transmitted through an Internet connection created by linking the IP address of the DS-L2 controller, using its own Web browser.

The cytotechnologist on site in the suite prepares the slides and transmits the images to the pathologist’s office at a resolution of 1,600 × 1,200 in 32-bit true color, with a lag time of 500 milliseconds in real time. A wireless phone connection is used for voice communication between the pathologist and cytotechnologist and the pathologist and clinician. “Fantastic” is how she describes the results.

Dr. Singh and colleagues decided to adopt telecytology only after studying its potential risks and benefits. Their first step was to conduct pilot studies using retrospective review and prospective assessment of endoscopic ultrasonographic-guided FNAs and CT-guided FNAs to verify concordance with in-person diagnoses.

“If concordance had not been similar to in-person assessment rates, I would not have been interested in pursuing telecytology. But it did not take me long to realize we had a very robust system on our hands,” she says.

All four cytopathologists in the practice participated in the pilot study. A single cytotechnologist transmitted the images through the telecytology system to their office computer screens. Blinded to the diagnoses, Dr. Singh and the other three cytopathologists provided their impressions, as if they were evaluating slides from active cases, for a total of 80 diagnoses.

To eliminate any possible bias from using only one cytotechnologist, the procedure was repeated on another set of pilot cases with all four pathologists and all four cytotechnologists participating. Each of the eight evaluators provided separate diagnoses for each case using Diff-Quik and Pap stained slides, for a total of 320 diagnoses.

The cytopathologists and cytotechnologists reviewed all cases blindly. The results were compared with the original final diagnoses, and the concordance rate was found to be 98.8 percent.

“The images were exactly the same as with a microscope,” says Dr. Singh. “Ten years ago, the cameras would not have permitted this quality.”

But the pilot studies did not end there. The cytopathologists then assessed 56 fine-needle aspirations in real time with telecytology, obtaining complete concordance with the final diagnoses in 53 of 56 cases, or 95 percent. This was compared with 100 cases performed with in-person assessments. In this group, complete concordance was seen in 97 percent. Results of the studies were published online in Diagnostic Cytopathology on Dec. 31, 2010 (Heimann A, et al. doi:10.1002/dc).

Based on these findings, Dr. Singh and her team felt confident establishing and adopting telecytology at their hospital. But would the clinicians embrace it? “I got no pushback. All our clinicians are onboard, even the new ones,” she says, attributing the acceptance to the pilot studies and the level of service provided.

As a result, for two years the pathologists and cytotechnologists at Stony Brook University Medical Center have performed telecytology for many of their radiologic and endoscopic fine-needle aspirations.

When Dr. Singh was preparing her paper for Diagnostic Cytopathology last year, little had been published on telecytology. That is beginning to change, with the literature now including references to telecytology being used for the immediate evaluation of fine-needle aspirations from many organ sites. Still, telecytology remains, in Dr. Singh’s words, a “well-kept secret.”

Establishing a telecytology protocol in a hospital requires a relatively small technological investment, along with the support and enthusiasm of other pathologists and cytotechnologists. “They have to be interested in cutting-edge techniques that will save their time,” she says.

No extraordinary level of information technology support is required. Dr. Singh says the IT support that exists in every laboratory today is sufficient.

She encourages interested colleagues to proceed systematically.

“Run your own pilot studies using archival material to determine what specimen types have concordance. If you find discordance, continue to do in-person assessments,” she advises. “You also need to determine what stains you will use and evaluate them in pilot studies. The facility for both Diff-Quik and Pap should be present.”

Positive results from the pilot studies can be used to allay concerns the clinicians may have. As added reassurance, she advises cytologists to inform clinicians that in-person assessments will be available if requested.

Finally, she suggests sharing the results with the pathology community: “When working with new technology, I strongly believe in working out the kinks, running your own pilot studies, gathering medical evidence necessary for implementation and publishing it, so that others can also benefit from your experience.”