Description of Rotation

The core cytology rotation for residents lasts 8 weeks, and is generally scheduled during the 2nd year of AP training. Its objective is to train residents in the evaluation of the wide variety of cytologic specimens: Pap tests, respiratory specimens, urine, body cavity fluids, gastrointestinal tract and pancreaticobiliary tree brushings, and fine-needle aspirations. Supervision is provided by Dr. Edmund Cibas. The coordinator is Ms. Dorothy Nappi, CT (ASCP).

A 3-week introductory rotation was added in 2003 for 1st-year AP and AP/CP residents.

A workstation, including a microscope, is provided for the resident in the Cytology Laboratory. The rotation includes a structured series of didactic teaching sessions ("tutorials"); responsibility for the work-up and final signout of cases; experience in performing fine-needle aspirations; review of glass slides from the teaching collection; and self study using standard cytology texts and web-based teaching tools. Residents are introduced to the principles of cytologic diagnosis by Cytology Division staff at one-on-one microscopic sessions (tutorials), during which Cytology staff review slides with the resident in an interactive fashion. Over 2500 glass slide teaching cases are available as a means of self-assessment to supplement the core curriculum of the tutorials. The residents are taught to perform fine-needle aspirations (FNAs), first by a hands-on tutorial, then by observation of real cases, and finally by performing FNAs themselves under supervision. Throughout the rotation, the importance of clinical decision-making is stressed, and communication of diagnoses to gynecologists, internists, and surgeons is encouraged.

Resident's Duties

1. Attendance at tutorials.

2. Daily review, evaluation, and written diagnosis of assigned cytology cases, according to a weekly schedule. Clinical service rotations are:

a. Non-gyn cases with cell blocks
b. Non-gyn cases without cell blocks
c. Gyn cases
d. FNA

In general, residents are assigned to one or two of these clinical service rotations every week. A detailed description of the resident's responsibilities during each of these rotations is provided below.

3. The BWH Cytology Lab has a glass slide teaching collection that is remarkable for its breadth and depth. There are over 2500 cases, most of them located in a dedicated file cabinet in MR-301. The resident should make an attempt to review as much of the collection as possible.

4. Attendance at fine-needle aspiration (FNA) procedures and performance of FNAs with supervision, at the discretion of a staff pathologist. Residents are required to keep a log of FNAs performed (form provided) and are expected to perform a minimum of 8 FNAs during their rotation.

5. Attendance at weekly and monthly cytology conferences. Attendance is required at:

A. Pap-biopsy Correlation Conference (Thursdays at 12:30 pm)
B. Weekly Cytology Case Conference (Wednesdays at 4pm).
C. Monthly Cytology-Radiology Conference

6. Reading cytology textbooks (see recommended reading below) and journal articles.

7. Communication with clinicians to request vital clinical information or to report a diagnosis.

8. Obtaining follow-up (such as biopsy results) on interesting cases.

Clinical Service Rotations

A. Non-gyn Cases With Cell Blocks

A large number of non-gynecologic cytology cases (e.g. pleural fluids, bronchial washings, needle rinses from FNAs) at BWH are prepared in part using the cell block method. This involves centrifuging a portion of the fluid sample, which yields a grossly visible cell pellet. This friable pellet is congealed into a solid mass using a few drops of plasma and thrombin, fixed in formalin, and embedded overnight in paraffin just like a punch biopsy. The cell blocks are cut the following morning (including Saturdays) in the Histology Lab and placed in a separate folder labeled "Cytology". Slides are usually available in the early afternoon.

In addition to the cell block, for each case there are also slides prepared in a more "conventional" cytologic manner (smears, cytospins, ThinPreps). These conventional preps are screened by a cytotechnologist, who jots down a written provisional diagnosis on the cytology requisition form, enters it into the computer, and places the cases with requisition form in a tray above the resident's desk labeled "Cytology Cases Waiting for Cell Blocks".

The resident's responsibilities on this rotation include:

1. Retrieving the cell block slides from Histology over the preceding weekend (alternatively, 7am Monday morning) and in the early afternoons Mon-Fri.

2. Matching up the cell block slides with the conventional cytologic preps.

3. Reviewing all slides, noting the cytotechnologist's provisional diagnosis. The resident pays particular attention to the cell block slides, dotting any unusual findings. (Cell blocks may reveal findings not seen on the conventional slides.) To prepare for Monday morning signout, the resident may come in on the weekend or early Monday morning (e.g. 7am) to retrieve and review the cell blocks that were cut on Saturday. Note: Preview of cases is optional during the first two days of the Cytology rotation, as some residents may still be busy finishing up cases from other AP services.

4. Reading portions of cytology textbooks and relevant journal articles related to the cases they are reviewing.

5. Recording the resident's own provisional diagnosis, and any questions, in ink on the requisition form. The resident should initial their provisional diagnosis.

6. Reviewing any cases marked RUSH with the senior the same day. All other cases are presented to the senior on NON-GYN service the next morning.

7. Following up on all their cases, including ordering special stains, entering HOLD notes, contacting clinicians with preliminary or final diagnoses as needed, and obtaining additional history or prior specimens for comparison as needed.

8. Delivering the cell block cassettes from Cytology to the Women's and Perinatal Division Cutting Room by 5:30 pm Monday-Friday. If the resident misses the cut-off for loading the processor, s/he is responsible for loading the cell block cassettes directly onto the processor.

9. On Friday afternoon, presenting all cases whose cell blocks come out that afternoon to the senior for review and possible signout. The resident is responsible for coordinating a mutually convenient time with the senior. The resident may choose to preview these cases, but (in the interest of time) this is not required. Because there is no Saturday morning signout in Cytology, this provides an opportunity to improve turnaround time by signing out cases on Friday rather than holding them over until the next week. Which cases are signed out by the senior on Friday, and which are left for the following week, is at the discretion of the senior on service that Friday. (Some non-urgent cases like peritoneal washings and thyroid FNAs are generally held over until the next week.)

10. Time permitting, attending several image-guided FNAs with the cytotechnologists. Dorothy Nappi, CT, can provide the resident with a schedule that lists the initials of the cytotech responsible for image-guided FNAs every day. The resident can coordinate with the cytotech to be notified whenever there is an image-guided FNA.

B. Non-gyn Cases Without Cell Blocks

Some non-gyn cytology cases, particularly urines and cerebrospinal fluids (CSFs), are not processed as cell blocks. The "conventional" slides from these cases are screened by a cytotechnologist, who jots down a written provisional diagnosis on the cytology requisition form, enters it into the computer, and places the cases with requisition form in a tray above the resident's desk labeled "Non-Gyn, Non-Cell-Block Cases".

The resident's responsibilities on this rotation include:

1. Reviewing the cases, noting the cytotechnologist's provisional diagnosis. To prepare for Monday morning signout, the resident can preview the cases the prior Friday afternoon (unlike cell blocks, no new slides arrive during the weekend). Alternatively, the resident can come in over the weekend or early Monday morning (e.g. 7am).

2. Reading textbook chapters and relevant journal articles related to the cases they are reviewing (particularly chapters on urine and CSF cytology).

3. Recording the resident's own provisional diagnosis, and any questions they may have, in ink, on the requisition form. The resident should initial their provisional diagnosis.

4. Reviewing all CSFs and any cases marked RUSH with the senior on NON-GYN service the same day. All other cases are presented to the senior on NON-GYN service the next morning.

5. Following up on all their cases, including, entering HOLD notes, contacting clinicians with preliminary or final diagnoses as needed, and obtaining additional history or prior specimens for comparison as needed.

C. Gyn Cases

Gyn cases (Pap tests) are screened by a cytotechnologist, who releases results on "negative" cases. Any case interpreted by the cytotechnologist as "reactive/reparative", atypical, SIL, or cancer must be reviewed by a pathologist. If a resident is on GYN service, the cytotechnologists will place gyn cases in a tray above the resident's desk labeled "Paps For Resident Preview".

When a resident is on a week of Gyn, cases will begin to appear on the resident's shelf throughout the day, starting at 8am the Friday before the rotation week. No new cases will appear after 8am on the Friday of the rotation week itself. This was designed to prevent "carry-over" of Gyn cases into the following week.

The resident's responsibilities on this rotation include:

1. Reviewing the cases, noting the cytotechnologist's provisional diagnosis.

2. Reading textbook chapters and relevant journal articles on gyn cytology.

3. Recording the resident's own provisional diagnosis, and any questions they may have, in ink, on the requisition form. If the resident agrees completely with the cytotechnologist's diagnosis, s/he may simply initial the requisition.

4. All cases marked RUSH are reviewed with the senior on GYN service the same day. All other cases are signed out with the senior the following day.

D. FNAs

The residents will attend a tutorial on FNA technique during the first week of the core rotation. After this introduction, they attend several procedures and observe fellows and senior staff perform aspirations. After observing several aspirations the residents are expected to perform aspirations themselves. The fellow or senior staff member always accompanies them.
The resident's responsibilities on this rotation include:

1. Carrying the FNA beeper (bb 15741). The FNA Center is open M-F, 8am - 4 pm, and is co-located with the Comprehensive Breast Center (Exit 4 off the Nesson Pike).

2. Scheduling FNAs. The resident will get paged to either perform an FNA immediately, or to schedule one for a future time. To schedule an FNA, the resident will check with the senior staff person's availability. Once a time is determined, the resident will call the Comprehensive Breast Center (2-8111) to make the appointment. The Comprehensive Breast Center is very busy on Thursdays, and it may not be possible to schedule an FNA on a Thursday. The resident will also fill out the top portion of the FNA Procedure Form, which is kept in a folder on the FNA Tray above the glass slide teaching collection.

3. Performing FNAs. The Comprehensive Breast Center receptionist will notify the resident when a patient has arrived for an FNA. The resident, accompanied by a fellow and/or senior staff person, will proceed to the FNA Center and perform the FNA.

4. Interpreting the results of all the FNAs that they perform. After recording a preliminary diagnosis, the resident brings the case to the senior staff for final interpretation.

5. Keeping a log of all the FNAs they perform. A copy of the final log is kept in their files by the program director.
6. Reviewing all FNAs (including non-palpable, image-guided cases) for a preliminary diagnosis. After the air-dried, Wright-Giemsa-stained ("DiffQuik" stained) smears have been screened by a cytotech, the case is placed in a tray marked "FNA station". The resident is responsible for previewing these cases as soon as they appear in this tray and bringing them to the senior staff person for a preliminary assessment. This "prelim" allows for rapid contacting of clinicians with important preliminary results, as well as expediting the ordering of special stains (e.g. no-bakes). After a hold note has been entered, the resident returns the folder to the cytotechnologist, who screens any alcohol-fixed, Papanicolaou-stained slides that come out later in the day. The case is then handled by the resident on one of the non-gyn rotations, depending on whether it has a cell block or not.

Available Teaching Materials

The Cytology Laboratory has a collection of over 2500 teaching cases, compiled over many years and continually updated. A teaching case consists of cytologic slides, pertinent clinical history, the final diagnosis, and, when available, histologic correlation. The Cytology Laboratory maintains an up-to-date collection of textbooks (see Recommended Reading below), journals, 35mm projection slide sets, and other reference materials, which are kept in the main laboratory and are easily accessible to the residents.

Recommended Reading

A. Recommended Texts:
1. Cibas ES and Ducatman BS. Cytology: Diagnostic Principles and Clinical Correlates, 2nd ed. (Saunders, Philadelphia, 2003). Short (less than 500 pages long) but comprehensive and up-to-date. Intended as a nuts-and-bolts reference for the practicing pathologist, it is also ideal as an introductory text for pathology residents.
2. DeMay RM. The Art and Science of Cytopathology (ASCP Press, Chicago, 1996). In two volumes and over 1200 pages long, this is widely considered the cytology "bible". Otherwise an outstanding reference with wonderful images.
3. Solomon D and Nayar R, eds. The Bethesda System for Reporting Cervical Cytology, 2nd ed. (Springer-Verlag, New York, 2004.) A short, state-of-the-art paperback affectionately known as the "blue book", it is a must for anyone learning to interpret Pap tests.

B. Recommended Web-based Learning Tools:

1. www.cytopathology.org/NIH. This web-based atlas consists of 349 images representing a range of morphologic findings seen on both conventional smears and liquid-based preparations. The majority of these images are from cervical/vaginal preparations; however, some anal-rectal preparations are also illustrated. Some are classic examples of an entity while others have been selected to illustrate interpretive dilemmas or "borderline" cytomorphologic features that may not be interpreted in the same way by all cytologists. The images have gone through a multistage review process. For each image, the preparation type, morphologic criteria and interpretation using the 2001 Bethesda System terminology are provided.
A subset of these images was used for the web-based Bethesda Interobserver Reproducibility Project (BIRP), which involved over 500 participants providing independent interpretations online. The resulting histograms showing the distribution of interpretations for these 77 images are presented on this website.
You also have the opportunity to take a "self test" comprised of 17 images with masked interpretations. After you provide your interpretation, your response is tallied along with all previous participants.

2. www.cytologystuff.com. CytologyStuff is an educational service provided by Cytyc Corporation, manufacturer of the ThinPrep instruments and supplies. This website features a learning module on ThinPrep® Pap Test morphology. There are newer modules on non-gynecologic (effusion, respiratory, and urinary) cytology as well as the automated ThinPrep Review Scope.

Objectives of the Cytology Rotation

At the end of the rotation, the resident should:

1. Understand Bethesda 2001 terminology for reporting Pap test results.

2. Be able to accurately recognize and diagnose the common benign, premalignant, and malignant lesions of the cervix and vagina.

3. Understand common terminology for reporting non-gynecologic and FNA specimens,
including the appropriate use of the "unsatisfactory" and "non-diagnostic" categories.

4. Be able to accurately recognize and diagnose the common benign, premalignant, and malignant lesions encountered in non-gynecologic specimens (urine, body cavity fluids, sputum, bronchial specimens, gastrointestinal brushings, and pancreaticobiliary brushings).

5. Be able to perform a fine needle aspiration of a superficial (palpable) mass.

6. Be able to perform an "immediate" evaluation of the adequacy of an FNA.

7. Be able to accurately recognize and diagnose the common benign and malignant lesions encountered in superficial and deep FNAs.

8. Be able to use ancillary techniques (immunocytochemistry, flow cytometry, and molecular diagnostics) to refine cytologic diagnoses as appropriate.

9. Be able to recognize the difficult cytologic case and appreciate the need for a second opinion in such cases.

Evaluation of the Residents

Evaluation of the residents is based on the ACGME guidelines for competency-based (outcomes-based) assessment, effective July 1, 2002.

1. Residents will be evaluated in writing by the cytopathologists and cytotechnologists involved in their training ("360 degree evaluation"). They will be assessed for their general knowledge and diagnostic competence; attendance, cooperation, and adaptability; responsibility, reliability, and judgment; and ability to communicate clearly.

2. Residents will take two slide examinations, one in gynecologic cytology and another in non-gynecologic and FNA cytology. The results of the examination will be reviewed with the resident by Ms. Dorothy Nappi, CT (ASCP).

Satisfactory completion of the rotation will depend on a satisfactory performance evaluation based on these measures.