Roseann I. Wu

Endoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-FNA) Contributes to a Triple Negative Test in Preoperative Screening of Pancreatic Cysts

BACKGROUND: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of pancreatic cysts obtains cyst fluid for cytologic and biochemical analysis, which may determine whether the cyst is mucinous and malignant, contributing to patient management. Despite this added value, EUS-FNA remains controversial in the preoperative assessment of pancreatic cysts. The objective of this study was to assess the utility of EUS-FNA in a cohort of small pancreatic cysts that were benign on imaging studies. METHODS: All pancreatic cysts that underwent initial EUS-FNA in 2006 and 2007 were retrospectively analyzed. Ninety-two patients with pancreatic cysts met the inclusion criteria. Patients who had high-risk or worrisome features on imaging studies were excluded. Cytology, histology, and cyst fluid analysis data were collected. The main outcome measurements were radiologic and clinical follow-up as well as cytopathologic and histologic results. RESULTS: EUS-FNA supported a diagnosis of a mucinous cyst in 38 of 92 patients (41%) by carcinoembryonic antigen (CEA) measurement and/or cytology. Cytology demonstrated an absence of high-grade atypia (HGA) in 89 of 92 patients (97%). The mean follow-up was 4.4 years (range, 0-7.7 years), during which 6 cysts were surgically resected and 16 cysts were resampled by at least 1 subsequent EUS-FNA. The overall negative predictive value of cytologic examination for HGA was 99%. CONCLUSIONS: EUS-FNA is a screening test that contributes to a triple-negative test for pancreatic cysts—no high-risk stigmata, no worrisome features, and no HGA on cytology—providing a negative predictive value of 99% for conservative management. Cancer (Cancer Cytopathol) 2013;000:000-000. V C 2013 American Cancer Society.

Implementation of an expanded point-of-care testing (POCT) site inspection checklist in a large academic medical center: Implications for the management of a POCT program

BACKGROUND Management of point-of-care testing (POCT) continues to present challenges. The use of site inspections by POCT coordinators has been a mainstay for maintaining regulatory compliance in POCT although this process is labor intensive. Improvements in device design and the use of POCT data management systems have improved the ability of hospitals to manage POCT programs. Given these developments, using regular site inspections to ensure regulatory compliance of POCT may be less relevant than in the past. METHODS We implemented an expanded POCT site inspection checklist modeled after the requirements of the Joint Commission. The checklist included categories not specifically related to POCT such as the environment of care and safety. RESULTS The average number of deficiencies per site in 2011 was 2.37 (range 0-10) out of a possible 42. Only 18% of site inspections produced no citations. In contrast in 2010 the average number of deficiencies per site was 3.17 (out of a possible 32) and only 8.7% of sites had no citations. The difference in the number of deficiencies per site was significant (t-test two tailed p=0.04). The most frequently cited deficiencies (24.2%) related to safety followed by maintenance of proper procedures and documentation of competency assessment. CONCLUSIONS Despite improvements in many POCT devices and data management systems, regular site inspections are still required to identify regulatory deficiencies and improve testing quality. The use of an expanded site inspection checklist will identify many areas for improvement that are not specifically related to POCT alone.

Adaptive eLearning modules for cytopathology education: A review and approach

Clinical training imposes time and resource constraints on educators and learners, making it difficult to provide and absorb meaningful instruction. Additionally, innovative and personalized education has become an expectation of adult learners. Fortunately, the development of web‐based educational tools provides a possible solution to these challenges. Within this review, we introduce the utility of adaptive eLearning platforms in pathology education. In addition to a review of the current literature, we provide the reader with a suggested approach for module creation, as well as a critical assessment of an available platform, based on our experience in creating adaptive eLearning modules for teaching basic concepts in gynecologic cytopathology. Diagn. Cytopathol. 2016;44:944–951.

Staining for acid-fast bacilli in surgical pathology: practice patterns and variations

Analysis of acid-fast bacilli stains on sputum smears for the diagnosis of tuberculosis has a long history, but quality control for acid-fast bacilli in histologic sections is not as well established. In tissues, necrotizing granulomas are closely linked to positive cultures for mycobacteria. However, the practices of pathologists examining acid-fast bacilli in surgical specimens are not well described in the literature. This study characterizes practice patterns related to the histologic interpretation of acid-fast bacilli stains. A survey invitation was sent to 1299 pathologists including members of the Pulmonary Pathology Society and randomly selected fellows of the College of American Pathologists. Twenty-one questions inquired about demographics, ordering and interpreting acid-fast bacilli stains, reporting, and correlation. Of the 392 responses (30.2% response rate), 363 respondents review acid-fast bacilli stains on histologic sections. Approximately half of respondents practice in an academic setting, with the other half in community practice. Most respondents examine the entire acid-fast bacilli slide with the ×40 objective; approximately half confirm the organisms under oil immersion at ×100. There was considerable variation in when an acid-fast bacilli stain is ordered, as well as possible additional workup for negative cases, reporting of results, correlation with clinical and culture findings, and training. Many respondents reported never having been taught a general approach to acid-fast bacilli interpretation. There is substantial variation in practice patterns involving all aspects of ordering, histologic examination, and reporting of acid-fast bacilli stains. Future efforts to standardize the interpretation of acid-fast bacilli stains can potentially improve the diagnosis of mycobacterial disease.

Müllerian adenosarcoma of the uterus with low-grade sarcomatous overgrowth characterized by prominent hydropic change resulting in mimicry of a smooth muscle tumor.

A 28-y-old woman was found to have a large subserosal uterine mass that was excised and interpreted as a “clear cell leiomyoma.” Five years later, the tumor recurred as serosal-based ileal and uterine masses; they were treated by partial ileal resection and hysterectomy. All 3 masses were predominantly characterized by conspicuous edema separating bland cells growing in cords and clusters, with scant to moderately conspicuous clear cytoplasm. The edema was indistinguishable from the hydropic change commonly seen in benign smooth muscle tumors and the cords similar to those often present in them. However, the mass from the hysterectomy specimen had a small, grossly recognizable cystic region, which on microscopic examination was a typical low-grade müllerian adenosarcoma. The stroma of the latter ranged from cellular endometrial-type to edematous and hypocellular similar to that dominating the other specimens. The cellular and edematous regions focally had cords and tubules of sex cord-like type confirmed by inhibin and calretinin positivity. Smooth muscle differentiation was also seen as a “starburst” pattern. This case of adenosarcoma is unusual due to its (1) serosal location, (2) overgrowth of stroma, which differed from typical adenosarcoma with sarcomatous overgrowth by its low-grade nature, (3) hydropic change associated with cords and nests of cells with clear cytoplasm, which prompted the initial specimen to be considered an epithelioid leiomyoma, and (4) prominent smooth muscle metaplasia mostly with a “starburst” morphology. All these features have only rarely been documented in prior müllerian adenosarcomas.

Giant cell arteritis causing symmetric bilateral posterior circulation infarcts.

An 82-year-old woman presented with bilateral, symmetric posterior circulation infarctions secondary to giant cell arteritis (GCA). Her atypical clinical presentation included a lack of headache and fever, but she exhibited signs of systemic illness including generalized weakness, cachexia, apathy, and anemia. Laboratory testing revealed a markedly elevated erythrocyte sedimentation rate, but only a borderline elevated C-reactive protein. Head and neck vascular imaging demonstrated a pattern of vertebral arterial narrowing consistent with GCA-a diagnosis confirmed by temporal artery biopsy. Her unusual symptomatic, laboratory, and imaging presentation highlights the importance of considering GCA in the differential diagnosis of unusual bilateral stroke syndromes, where early treatment decreases morbid outcomes.

Molecular Cytology Applications on Pancreas and Biliary Tract

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endoscopic retrograde cholangiopancreatography (ERCP) are today’s standard of care methods for obtaining a tissue diagnosis from the pancreatobiliary tract. The cytologic examination of material collected by either EUS-FNA or ERCP is usually sufficient for diagnosing the majority of pathologic conditions associated with the pancreatobiliary system. In addition to the essential role of cytomorphology for patient diagnosis and management, ancillary tests such as immunocytochemistry and molecular testing can be used to support the morphologic impression. Indeed, immunocytochemical stains for pancreatic neuroendocrine tumors, fluorescence in situ hybridization (FISH) for the evaluation of biliary tract strictures, and molecular analysis of KRAS gene mutations to support the diagnosis of pancreatobiliary carcinomas have been accepted as reliable ancillary tests applied to cytologic specimens. However, controversies exist regarding the routine implementation of such tests due to limitations such as the need for a substantial amount of diagnostic material, the labor-intensive and time-consuming nature of some of the techniques, the moderate specificity, difficulties in interpreting the results, and the relative costs of molecular methods. Currently, there is not sufficient clinical evidence to support widespread adoption of most molecular tests. Nevertheless, recent studies and new techniques, such as next-generation sequencing (NGS), could provide more comprehensive knowledge of the molecular landscape of pancreatobiliary tumors that may result in the discovery of biomarkers for future targeted therapies.

Expanding Opportunities for Professional Development: Utilization of Twitter by Early Career Women in Academic Medicine and Science

The number of women entering medical school and careers in science is increasing; however, women remain the minority of those in senior faculty and leadership positions. Barriers contributing to the shortage of women in academics and academic leadership are numerous, including a shortage of role models and mentors. Thus, achieving equity in a timelier manner will require more than encouraging women to pursue these fields of study or waiting long enough for those in the pipelines to be promoted. Social media provides new ways to connect and augments traditional forms of communication. These alternative avenues may allow women in academic medicine to obtain the support they are otherwise lacking. In this perspective, we reflect on the role of Twitter as a supplemental method for navigating the networks of academic medicine. The discussion includes the use of Twitter to obtain (1) access to role models, (2) peer-to-peer interactions, and continuous education, and (3) connections with those entering the pipeline—students, trainees, and mentees. This perspective also offers suggestions for developing a Twitter network. By participating in the “Twittersphere,” women in academic medicine may enhance personal and academic relationships that will assist in closing the gender divide.

The utility of adaptive eLearning in cervical cytopathology education

Adaptive eLearning allows students to experience a self‐paced, individualized curriculum based on prior knowledge and learning ability.

The Cytopathology Program Directors Committee - Creating Valuable Tools for Cytopathology Fellowships

The Cytopathology Program Directors Committee (CPDC) is charged by the American Society of Cytopathology (ASC) to anticipate and address changes in clinical practice that need to be included in fellowship training, develop the Strategies in Cytopathology Education Course for Cytopathology Fellowships held at the ASC Annual Scientific Meeting yearly, regularly engage Program Directors, and continually develop and share best practices in education. In the last few years, many changes in accreditation policies for cytopathology fellowships have transformed much of the administrative work for Program Directors. Therefore, the CPDC has been focusing on creating tools and accumulating resources for Fellowship Program Directors to assist with these issues.