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Cytopathology in Focus: Glass slide programs to have latest terms, ancillary clues

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Barbara A. Crothers, DO

Why glass slides are being reclassified, one body site at a time

August 2016—Why is there more than one correct answer for this glass slide case? I wouldn’t make the diagnosis of mesothelioma without correlating with the clinical history and performing ancillary studies. In our practice, we would call this case a follicular lesion of undetermined significance, and that isn’t an answer on the response sheet.

Metastatic ductal carcinoma. Lymph node fine needle aspiration, modified Giemsa stain, high magnification.

Metastatic ductal carcinoma. Lymph node fine needle aspiration, modified Giemsa stain, high magnification.

You asked and commented (a few examples above), and we listened. The CAP Cytopathology Committee is renovating and updating the Fine-Needle Aspiration and Nongynecologic Cytopathology Education glass slide programs. The slides in these programs, as in the Pap Education Program, receive a precursory review for damage, fading, and coverslip problems when they are sent back to the CAP and before they are returned to the program. This filters out the well-worn slides. Simultaneously, new slides are entered into the program every quarter after three pathologists on the Cytopathology Committee review and accept them. If all three pathologists agree that the slide represents a well-stained, well-prepared, and accurate example of the interpretation, it is accepted into the program to replace retired slides.

But is this good enough? Cytopathology Committee members thought not. Over the years, the practice of cytopathology has expanded and become more complex. Biopsies have gotten smaller and the use of cytopathology as a diagnostic tool has become common. Touch imprints of core biopsies are employed to assess for biopsy adequacy and ensure that diagnostic tissue is obtained. The use of ancillary tests, such as immunocytochemical studies, flow cytometry, genotyping, FISH, and molecular analysis for mutations and translocations, is the standard to maximize minimal tissue. Pathologists and cytotechnologists routinely investigate electronic medical records to harvest information about clinical, radiographic, and laboratory findings that may help to narrow a differential diagnosis. The CAP cytopathology educational programs are intended to mirror actual clinical practice as closely as possible but had been lacking these ancillary clues. Time for a change: time to provide pathologists with all of the information they need to make the most specific interpretation possible and minimize catchall interpretations such as “metastatic malignancy” and “non-small cell carcinoma.”

Metastatic ductal carcinoma. Lymph node fine needle aspiration, positive HER2 immunocytochemistry, high magnification.

Metastatic ductal carcinoma. Lymph node fine needle aspiration, positive HER2 immunocytochemistry, high magnification.

Since 1991, with the introduction of the Bethesda System for Reporting Cervical/Vaginal Cytologic Diagnoses, the cytopathology community has been progressively moving toward standardized diagnostic terminology to improve diagnostic understanding of cytology reports. The Bethesda System for Pap test terminology has been updated several times, most recently in 2014. In 2007, the Bethesda System for Reporting Thyroid Cytopathology expanded those efforts into fine needle aspiration specimens. Then came the Papanicolaou Society of Cytopathology’s standardized terminology and nomenclature for pancreaticobiliary cytology, the American Society of Cytopathology/International Academy of Cytology Paris System for Reporting Urinary Cytology, and the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society International Multidisciplinary Classification of Lung Adenocarcinoma. Still evolving is an international effort to propose standardized terminology for reporting salivary gland cytopathology. These new directions provided committee members with the opportunity to update the terminology used in the glass slide program to support cytopathology organizations’ recommendations for the use of standardized terminology.

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