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Cytological Examinations - Frequently Asked Questions

Cytopathology  is a branch of pathology that studies and diagnoses diseases on the cellular level. The discipline was founded by George Nicolas Papanicolaou in 1928. A common application of cytopathology is the Pap smear, used as a screening tool, to detect precancerous cervical lesions and prevent cervical cancer. Cytopathology is also commonly used to investigate thyroid lesions, diseases involving sterile body cavities (peritoneal, pleural, and cerebrospinal), and a wide range of other body sites. It is usually used to aid in the diagnosis of cancer, but also helps in the diagnosis of certain infectious diseases and other inflammatory conditions. Cytopathology is generally used on samples of free cells or tissue fragments, in contrast to histopathology, which studies whole tissues.

Cytopathologic tests are sometimes called smear tests because the samples may be smeared across a glass microscope slide for subsequent staining and microscopic examination. However, cytology samples may be prepared in other ways, including cytocentrifugation. Different types of smear tests may also be used for cancer diagnosis. In this sense, it is termed a cytologic smear.

Cytopathology is frequently, less precisely, called cytology, which means "the study of cells."

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What is cytology?

Cytology is the study of individual cells and cytopathology is the study of individual cells in disease. Sampled fluid/ tissue from a patient is smeared onto a slide and stained (see techniques). This is then examined under the microscope by the anatomical pathologist to look at the number of cells on the slide, what types of cells they are, how they are grouped together and what the cell details are (shape, size, nucleus etc). This information is useful in determining whether a disease is present and what is the likely diagnosis.

Cytology is most often used as a screening tool to look for disease and to decide whether or not more tests need to be performed. An example of screening would be the investigation of a breast lump. In combination with examination by the clinician and imaging tests, a needle aspirate of the lump submitted for cytology will show whether the breast cells are suspicious for cancer or look bland/ benign. If they look suspicious, a core biopsy with a larger needle may be performed which takes more tissue, allowing for a definitive diagnosis to be made before deciding what type of surgery is required (local removal of the lump or removal of the whole breast).

What is a Fine Needle Aspiration (FNA)?

A fine needle aspiration (FNA) is a biopsy technique used to sample potentially abnormal tissue. This technique can be used for patients with either superficial or deep nodules. If the lesion is deeper and cannot be felt, imaging techniques, such as an ultrasound or CT, can be used to localize the lesion for FNA. Using sterile technique, a small needle is introduced into the mass and quickly moved back and forth to remove cells. This may be performed multiple times. The cells are placed on glass slides, stained, and examined under a microscope in order to provide a diagnosis. The pathologist or cytotechnologist may review the glass slides at the time of the procedure to decide whether or not additional samples are needed [this is called a rapid on-site adequacy assessment]. Depending on the type of cells present, additional tests may be performed to determine the final diagnosis.

What are the advantages of FNA?

FNA is a rapid procedure with minimal discomfort for the patient. The actual procedure takes only 10-20 minutes, but the entire process can take up to an hour or more if imaging or rapid on-site adequacy is necessary. Rapid on-site adequacy assessment reduces the chance that the biopsy will need to be repeated by ensuring that diagnostic material is present. This may save the patient an additional trip back to the doctor’s office or hospital. Since FNA is minimally invasive and it uses a very small needle, it is generally well-tolerated and typically requires little recuperation following the procedure. Results are usually available within a few days.

Who performs the FNA?

FNA is usually performed by a trained physician. Rapid on-site adequacy assessment, if available, is performed by a pathologist or certified cytotechnologist. All of the slides and additional test results, if necessary, are examined by a pathologist, who gives a final diagnosis. This information is typically written in a report and given to the treating physician, who will inform the patient of the findings.

Is an FNA painful?

One of the advantages of FNA is that it is a relatively pain-free procedure. For superficial lesions, anesthetic (such as lidocaine) is typically not necessary. The needle used is smaller than the needle used to draw blood. Patients feel a “poke” during the initial entrance of the needle after which a sensation of pressure is most commonly described. Biopsies of deeper locations, visualized by imaging techniques, may require sedation and/or anesthetic. Sedation is not indicated for FNAs of superficial or palpable (‘feel-able’) masses performed in the clinic or doctor’s office.

How are the FNA results obtained?

We have found that FNA results are more accurate when the doctor who performed the biopsy also interprets the sample. The doctor who performed your biopsy will personally examine your slides and determine the diagnosis. In all cases, we phone the results of this test to your physician by 3 P.M. the following work day. We also mail a written report to your doctor’s office. If you wish to know the results of your biopsy before your next scheduled appointment, contact your doctor directly. He can best explain exactly what the test results mean for you and what, if anything, should be done next. However, if you are unable to reach your doctor, please call our office.

How accurate are the results from an FNA?

FNA is a quick and accurate way to determine the cause of the abnormal nodule or mass. Possible causes include infectious, inflammatory, and cancerous diseases. Often the FNA diagnosis will provide all of the information the clinician needs to determine treatment. In some cases which are usually related to the nature of disease, further diagnostic testing, either by repeat FNA or other tissue sampling technique, may be necessary.

Are there any complications of FNA?

Any time the skin is broken there is a chance of infection. To minimize this risk, the skin is cleaned prior to the procedure and sterile needles and syringes are used for each sampling pass. Bleeding, usually very minimal, is controlled with pressure after the needle is removed. A Band-Aid is usually placed over the FNA site when the procedure is finished. Slight bruising and mild soreness afterward are common. After the procedure, the patient can return to their normal activities without any restrictions. As with any health concern, it is best to call your doctor to report any unexpected post-procedure developments, such as moderate to severe pain, swelling, heat, or numbness, and to proceed to the emergency department if symptoms are severe.

What do I have to do to prepare for an FNA?

If the site to be biopsied is superficial (can be felt), no preparation is needed. Discuss with your doctor beforehand if you are taking aspirin or other blood thinners, have a history of a bleeding disorder, or have low platelets. If the nodule or mass is deep and requires imaging to be visualized (for example, in the lung), you will receive pre-procedure instructions either from radiology or the team performing the FNA

Why are high quality cytopathology services important?

High quality services are critical for diagnosis,screening,treatment and follow up.Alpha Prolipsis CytoPathology Laboratories believe in prompt communication. This helps the physician provide the diagnosis and treatment option to the patient as soon as possible. High quality cytopathology service helps the physician provide their patients the correct answers that they are waiting for.

Why is it important that physicians choose their cytopathologist?

As mentioned above the cytopathologist is known as “the doctor to the doctors”. Just as you need to have a good relationship with your physician, your physician needs to have a close relationship with the cytopathologist.

Why is cytology worth performing?

Cytological examination is a painless examination of the cervix, which enables to detect early preneoplastic and neoplastic lesions when they don't cause subjective symptoms and may not be visible in a gynaecological examination. Cytology can detect minimal lesions on the cervix, which qualify for local treatment, without the necessity to perform an extensive abdominal surgery, which takes place in case of major lesions. It should be stressed that microscopic advancement of the lesion allows to remove them with no harm to procreative potential, especially of young women.

How should I prepare for cytological examination?

Material for cytological examination is collected before gynaecological examination, Transvaginal ultrasound, bacteriological test (culture) or virological test from the vagina and/or cervical canal. Cytological examination can be performed about 4 days after menstruation and up to 7 days before next expected menstruation (preferably between 10th and 20th day of the cycle – first day of the cycle is the first day of menstrual bleeding).
At least 4 days before cytological examination no intravaginal medications/preparations, intravaginal tampons or vaginal lavage can be applied. 24 hours before cytological examination one must refrain from sexual intercourse. 24 hours before cytological examination no gynaecological examination or transvaginal ultrasound can be performed and no material for bacteriological test (culture) or virological test can be collected from the vagina and/or cervical canal. In case of vaginal inflammations it is necessary to cure them before collection of material for cytological examination.

How long do I have to wait for the results of cytology?

It takes about 2 days to get the results of your cytology in our laboratory.

What is exfoliative cytology ?

This is the analysis of cells that are shed from body surfaces. Examples include the lining cells of the uterine cervix (mouth of the womb) and of the bladder. The analysis of cells from the cervix is a minimally invasive procedure called a cervical or Papanicolaou smear (Pap smear). This involves the insertion of a speculum into the vagina to allow the clinician to directly view the cervix. The cervix is then gently scraped to retrieve cervical cells which are smeared directly onto glass slides at the bedside and submitted to a laboratory for examination. The material from the cervical scrape can also be directly tested for wart virus (Human Papilloma Virus), the major risk factor for the development of cervical cancer.

What is aspiration cytology ?

This is the analysis of cells from within a mass or organ. This involves a more invasive sampling procedure called Fine Needle Aspiration (FNA). A needle is inserted into the area of the body being examined, sometimes with the use of imaging (e.g. ultrasound or CT scan) to ensure that the suspicious area is being sampled. This procedure may be performed after injection of local anaesthetic to numb the skin, or even under light sedation if involving a deep organ or tissue. The cells retrieved are expressed onto a slide and prepared in a similar way to the cervical smear. If fluid is aspirated (e.g. within from a thyroid cyst), it may first be spun by a centrifuge so that the cell-containing sediment collects at the bottom of the test tube, allowing the best material to be sampled for examination.

Examining cytology material

The most common samples in cytology are exfoliative, including cervical smears (Pap smears), urine and sputum. These are usually screened by trained cytotechnicians or, in some laboratories, computerised automated systems, to look for any suspicious cells. Suspicious samples are forwarded to a pathologist for further microscopic examination and final diagnosis. Aspirated material is usually viewed by a pathologist directly.
Special stains are performed to highlight the cells and background material on the slide, in a similar way to histopathology sections.

Detailed Specimen Collection Instructions

General Labeling and submission instructions - All specimens must be accompanied by a Cytology Requisition that includes the patient name, medical record number, source of specimen and the submitting physician’s name. Any submitted microscope slides must be labeled with the patient’s name and medical record number using a pencil. Pertinent clinical history should be provided, and is essential for samples referred from outside the laboratory's medical record system.

Turn around time - Turn-around time for Pap tests averaged 1.6 days in 2015. Routine Non-GYN cytologies have a turn-around time of about 90% in 2 days. Stat diagnostic requests can be requested, allowing diagnosis within 24 hours of receipt of the sample (same day for specimens received before 1PM) including cases with cell blocks. FNAs performed by Cytopathologists, or onsite evaluation by Cytopathology of clinician-performed FNAs (see FNA service) allows a definitive diagnosis in the majority of cases within minutes.

Specimen Types:

BEST Prep Pap tests, colposcopic endocervical brushing, and HPV testing
Fine needle aspiration (FNA) biopsies
Pleural, peritoneal and pericardial fluids
Urine Cytology
Brush cytology
Anal pap tests
Tzanck prep for Herpes
Amyloid detection

A. BESTPrep Pap tests: The BESTPrep vial must be labeled with the patient’s name and medical record number. Obtain cellular material as per CELLSOLUTIONS instructions from the cervix using a spatula, endocervical brush or broom device. Avoid collecting a sample at time of menses, or in the presence of a severe purulent discharge. The goal is to capture exfoliated cells from the transformation zone, and to sample the endocervix. For BEST prep paps, immediately agitate the brush in the liquid fixative, against the inside of the container, to dislodge all mucous. It is essential to immediately dislodge the cells because the endocervical component becomes irreversibly fixed to the bristles after about 15 seconds.

B. HPV testing: Screening for high-risk types of HPV (“HR-HPV”) is available on material collected in BESTPrep vials with or without morphologic evaluation. Indicate on the cytology requisition whether HPV testing is needed, and whether testing should be only reflexed to patients with atypical squamous cells of uncertain significance. Reflex genotyping for HPV types 16/18 can also be requested (for patients with negative morphologic results by positive HR HPV screen results.

C. Conventional Pap smears: Avoid collecting a sample at time of menses, or in the presence of an untreated infection. Transfer the material in one or two strokes (do not over-smear) and immediately spray fix the slide from a distance of about 12 inches with Cytology Spray Fixative, thoroughly saturating the cells. Allow the spray fixative to dry before sending the slide. HPV testing is not available on conventional pap tests.

D. Colposcopic Endocervical Brushing: Use an endocervical brush, preferably with a plastic straw covering the bristles. The purpose of the straw is to minimize collection from the portion of the cervix that can be directly visualized. Label a container of fixative or a BESTPrep vial . Under Coloposcopic guidance, put the end of the straw at the endocervical os. Exend the brush 1-2 cm through the straw into the endocervical canal. Rotate the brush only 1 revolution. Withdraw the brush back into the straw. Extend the brush out of the straw into the fixative. Immediately dislodge sample from the bristles by rotating the brush against the inside of the specimen collection container. Endocervical curettage rather than colposcopic brushing is recommended as a follow-up for atypical glandular cells in a pap test.

E. Fine needle aspirates: The technical aspects of performing an FNA and triaging material for diagnosis are not trivial. Click here for a full description of the technique. Four options are available.

1. It is preferable for the staff Cytopathologists to perform FNAs of any palpable lesion at the bedside or in an outpatient setting . The non-diagnostic rate for Cytopathologist-performed FNAs is significantly lower (about 15%) than FNAs performed by clinicians (about 30%) because we assess the adequacy of the sample while we do the procedure and triage material for needed ancillary studies. Cytopathology is available on a Stat basis between 8:30 and 21:30 Monday through Friday, or patients can be scheduled and registered to be seen by Cytopathology;s staff. Cytopathology can help answer patients’ questions, but we generally only give diagnoses to the referring clinician. We administer local anaesthetic (if needed), and can provide a definitive diagnosis within minutes for the majority of cases. Conversely, we can know within minutes if a larger core biopsy is needed and can refer patients to Surgery or radiology for the original physician.

2. For non-palpable lesions, or if a clinician prefers to perform the FNA, we recommend scheduling an immediate diagnostic evaluation of the FNA . This is highly recommended if the procedure is performed under radiographic guidance or if lymphoma is suspected. We will prepare the smears, triage material for ancillary studies such as microbiology, flow cytometry, and cell block preparation and provide a rapid assessment of adequacy of the sample with a turn-around time of about 15 minutes. In most cases, a definitive diagnosis can be rendered within minutes.

3. For clinician-performed FNAs without on-site evaluation, please refer to the link providing detailed technical instructions. Rinse of the needle in solution (available from Cytology ) and shake the container to disperse the sample. Note that the solution lyses red cells after about 15 seconds. After the red cells are lysed, there should be visible particles if the FNA is adequate.

F. Pleural, peritoneal and pericardial fluids: Do not add any fixative. If the sample is grossly bloody, it is preferable to collect the sample directly into a container containing at least 2 units per ml heparin.

G. Urine: A clean-catch, mid-stream, fresh voided urine is optimal as a screen for bladder cancer. 50 ml is adequate. Add one volume of Saccomanno’s fixative (which contains mixed alcohols and 2% polyethylene glycol) to the sample at the time of collection. If microbiology and urinalysis is needed, split off part of the sample for these studies before adding fixative. Avoid sampling during a clinical urinary infection, or during a bout of gross hematuria, otherwise the urothelium can be too diluted with inflammatory cells or blood cells. A 24-hour urine is not satisfactory for diagnosis because the cells will be degenerated. Two or three samples on different days have been shown to boost sensitivity of the test.

I. CSF: At least 1 ml CSF is needed for cytopathology. Send the sample promptly to the cytology laboratory so that the cells can be prepared before they degenerate. If the sample is collected on Friday, add one volume of Saccomanno’s fixative to prevent degeneration in case the sample is delayed over the weekend. If flow cytometry is needed, a separate aliquot of at least 3 mL of fresh, unfixed CSF is required. CSF samples for flow cytometry should be separately submitted to Hematopathology who will issue the reports. Separate samples also must be sent for cell count studies, handled by the Hematology lab.

J. Pelvic and Peritoneal Washing fluid specimens: The washing/lavage fluid should be a physiologic solution (E.g. Lactated Ringer’s, Normosol, or Hank’s) rather than normal saline. Write “refrigerate” and deliver promptly.

K. Other Lavage fluid specimens: Other useful specimens for diagnosis include lavages of the pulmonary tree or various GI sites. The lavage fluid should be a physiologic solution (E.g. Lactated Ringer’s, Normosol, or Hank’s) rather than normal saline. Write “Refrigerate” and deliver promptly.

L. Sputum samples: An induced sputum is optimal. Have patient rinse mouth with water thoroughly before collecting sample to decrease the number of oral squamous cells, which otherwise obscure the pulmonary sample. In order to be adequate for diagnosis, the specimen must consist of a high proportion of pulmonary material since the pulmonary tree sheds so few cells compared to the oropharynx. Write “Refrigerate” and deliver promptly. If collected on Friday add one volume of Saccomanno’s fixative (available from Cytology ) to preserve cells in case they cannot be processed over the weekend.

M. Brush samples (e.g. GI tract, biliary tract, and bronchial tree): If only one brushing per site is performed, use fixative (provided by Outreach Supplies or Cytopathology). Immediately swirl the brush against the side of the fixative's container, or immediately retract and extend the brush within the plastic sleeve (for some brush designs) in order to dislodge the cells. It is essential to dislodge cells from the brush within about 30 seconds because the cells will become permanently fixed to the bristles of the brush. It is not necessary to cut off the brush. If more than one brushing per site is performed, dislodge the sample into 2 ml of normal saline as described above, then repeat the brushing as many times as needed to sample the area, and finally transfer the 2 ml of saline (containing the sample) into at least 10 ml of cytorich red fixative. If scheduled in advance, an immediate intra-procedural diagnostic evaluation by cytopathologist may be able to be performed.

N. Anal pap tests: Screening for anal squamous cell carcinoma in high risk individuals involves use of Dacron-type swab with a sturdy plastic handle (not provided by Cytology). The swab is pre-moistened with water, inserted about 1-2 inches, and rotated one to two revolutions. Rinse the sample into a BESTPrep vial. HPV testing is also recommended.

O. Tzanck prep (Skin scrape cytology to rule out herpes infection): Use fixative (provided by Cytopathology) Moisten the skin for a few minutes by placing a paper towel saturated with water over the area. Scrape the blister with the edge of a clean microscope slide. This microscope slide may be pre-cleaned/sterilized before use with an alcohol-soaked pad. The blunt edge of a scalpel blade or a pap test brush may also work. Put the edge of the microscope slide into the fixative (or brush or scalpel blade) and immediately agitate to dislodge the (often sparse-appearing) sample.