Update on Telecytopathology

| September 9, 2015

Re-posted from CAP TODAY:

Screen Shot 2015-09-03 at 7.30.43 PMThere is a growing body of literature referencing the uses of telecytopathology in clinical care. Telecytopathology (TCP) is the interpretation of cytopathology material at a distance using digital images. Although there is a long history of attempts at implementing TCP for broad clinical use, it still has limited, but important applications in patient care. While the technology has improved from low-grade video quality images to higher-grade static digital images and more recently, whole slide imaging with sub-micron resolution scanning capabilities, the nature of cytology material itself, both in terms of quantity and often quality of cells that can be imaged and viewed at a distance remains a challenge. Cytology material often is not as uniform as formalin-fixed paraffin embedded tissue in terms of thickness for focusing and cells with three-dimensionality may be spread across an entire slide compare with conventional histology processing. The use of multiple stains to detect subtle features, such as Papanicolaou and Romanowsky in tandem, may increase the number of slides to be viewed and limiting digital pathology techniques to perform assessments in a timely manner (1).

While fine needle aspiration (FNA) is certainly not a new technique, recent developments in advanced imaging techniques, molecular testing and targeted therapies have coincided with a rapid increase in the number of FNA procedures being performed (2).

Consequently, the demand for rapid on-site assessment (ROSA) has also increased, outstripping the capacity of available cytopathologists at many institutions.

TCP is being increasingly used with cytotechnologists and cytopathologists to support ROSA procedures. The technology has been demonstrated to reduce the need for an on-site cytopathologist while still insuring that pathology support is provided for these patients and adequacy and triage determinations are met at the appropriate for handling of cytology and core biopsy material (1,3,4).

Recent literature suggests that when properly implemented with sufficient training on the application, TCP can be an effective technology for “telecytopathologists” with remote cytotechnologists for determining adequacy and reducing the non-diagnostic rate for many specimen types, including, but not limited to thyroid and endoscopic ultrasound-guided fine-needle aspiration procedures (5,6).

The ability to support remote office settings and imaging departments where collection of cytology specimens may be at a distance from the pathologist and cytology departments for immediate evaluation is critical to the cytology community. The ability to provide appropriate assessment in a timely manner that is minimally disruptive to the workflow of the department and individuals providing these services will become increasingly important with changes in healthcare delivery systems on the horizon and patients being cared for in larger integrated healthcare delivery systems where members of the healthcare team are at an increasing distance from both the patient and the provider.

Not only may a telecytopathologist be able to provide immediate support for a cytotechnologist or cytopathology fellow at the time of collection, all members of the team involved in the care of the patient are afforded an opportunity to collaborate with colleagues during the procedure without the need for on-site assessment beyond collection and initial screening. Deliverables include minimal disruption to others viewing the images and enhanced capability to have multiple simultaneous reviewers for consensus opinion, minimizing diagnostic errors.

TCP continues to be an evolving area of telemedicine. Guidelines for primary opinion TCP should be driven by best practices in conventional laboratory procedures with an understanding of legal and regulatory environment in your locations and institutions to assure safe, quality patient care protocols. More than ever before, pathologists often work in central offices geographically separated from the clinics, where cytology and surgical samples are obtained, and the histology laboratories, where cytology preparations and tissue are processed and slides are made. As pathology becomes increasingly subspecialized, and pathologists are progressively more engaged in practice situations where they may not be in a centralized laboratory location, the use of TCP can enhance the practice of pathology (6).

The practice of cytology is evolving, and cytologists must prepare now for the “digital” tomorrow. In the coming years, several changes such as the advancement of personalized medicine, adoption of image standards, and the emergence of technological advances like digital pathology will greatly impact how a cytologist performs his/her job. Early efforts to use digital images and the Internet to render diagnoses via TCP have shown promise despite suboptimal older technology that initially was restricted to reproducing only a tiny fraction of the material on a glass slide. Whole slide imaging offers the prospect of true virtual microscopy, and may in time even replace glass slides in routine practice. We are rapidly approaching this reality as vendors continue to build newer, faster, and cheaper scanners with sophisticated software to improve digital pathology workflow. The potential for TCP is only just beginning to be realized. Cytologists can look forward to accessing, reviewing, sharing, and even analyzing the digital data in their “digitized” slides (1).

References:

  1. Thrall M, Pantanowitz L, Khalbuss W. Telecytology: Clinical applications, current challenges and future benefits. J Pathol Inform 2011;2:51. PMID: 22276242.
  2. Collins JA, Novak A, Ali SZ, Olson MT. Cytotechnologists and on-site evaluation of adequacy. Korean J Pathol 2013;47:405-410. PMID: 24255627.
  3. Khurana KK, Graber B, Wang D, Roy A. Telecytopathology for on-site adequacy evaluation decreases the nondiagnostic rate in endoscopic ultrasound-guided fine-needle aspiration of pancreatic lesions. Telemed JE Health 2014;20:822-827. PMID: 25093731.
  4. Gerhard R, Teixeira S, Gaspar da Rocha A, Schmitt F. Thyroid fine-needle aspiration cytology: is there a place to virtual cytology? Diagn Cytopathol 2013;41:793-798. PMID: 23441010.
  5. Alsharif M, Carlo-Demovich J, Massey C, et al. Telecytopathology for immediate evaluation of fine-needle aspiration specimens. Cancer Cytopathol 2010;118:119-126. PMID: 20544707.
  6. Kaplan KJ. Telecytopathology for immediate evaluation of fine-needle aspiration specimens [Editoral]. Cancer Cytopathol 2010;118:115-118. PMID: 20544703.

Source: CAP TODAY

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