Cytopathology

Goals and Objectives

The standard training consists of four blocks of cytopathology. The first block in PGY2 is introductory in nature and is followed by two blocks in PGY-3 or PGY-4 and one block in PGY-5, during which knowledge is extended and fortified.  Depending on resident interest and availability additional elective block(s) may be undertaken with approval of the Director of Cytopathology.

Level: PGY-2, PGY-3, PGY-4 and PGY-5

For case review in Cytopathology residency training, there is no separation of cases based on complexity.  Due to the nature of Cytopathology (all cases are ultimately reviewed and finalized by a supervising staff), a resident in any training level can review the glass slides and write up a preliminary report on any cytopathology case.

  • Ordering of any ancillary studies (histochemical stains, immunohistochemical stains, molecular testing) will be done under staff supervision.  This is done in order to conserve tissue and prevent tissue waste that may limit the staff pathologist's ability to render a diagnosis or enable molecular testing to ensure initiation of timely patient treatment.
    • Based on the resident's experience and abilities they may eventually be permitted to order additional ancillary stains for straightforward, routine cases without consulting the staff pathologist. This is at the discretion of the supervising staff.
    • Regardless of previously agreed upon permission to order stains, any challenging case for which the resident is unsure of cell lineage, is unable to formulate a differential diagnosis that would be resolved by ancillary testing, or is unsure of the clinical significance or timeline of the biopsy material, the resident must consult the staff pathologist before ordering any ancillary stains.

 

The first cytopathology rotation is introductory in nature and consists of several one-on-one teaching sessions which will be led by the cytotechnologists to develop a consistent approach to reviewing cases (ie. check site and relevant clinical history, low power impression, begin to identify cell types and background, high power evaluation of lesional cells).

Subsequent cytopathology rotations will be built on this foundation and include the ability to accurately describe cytomorphology, formulate reasonable differential diagnoses, work up challenging cases, and be able to identify the most likely clinical management decisions based on the rendered diagnoses, being cognizant of staging considerations and critical results. The supervising staff pathologist is expected to provide an appropriate volume of cases for review based on the resident’s level of training with the understanding that greater responsibility and workload will be taken on starting in PGY-3.

A senior resident should be able to produce a draft cytopathology report consisting of an appropriate diagnosis and microscopic description and/or comment field.  This draft report should also be free of typographical errors. Senior residents are expected to begin to understand the nuances of various preparation methods (liquid based versus smears versus cell blocks) and various stains (alcohol fixed versus air dried).

It is expected that the residents at all training levels will familiarize themselves with the most common standardized reporting systems in cytopathology (ie. Cervix, Thyroid, Urine, Pancreas, and Salivary gland, see 'Suggested Reading' below).     

The PGY-5 year is one of senior leadership and the resident should be able to assume responsibility for organizing the service and supervising junior residents and students. The resident should have mastery of the information contained in standard texts and be prompt in using the literature to solve specific problems. The resident will be responsible for teaching junior residents and students on a routine basis, and be available to clarifying questions about rotations, EPAs and the general workflow in the cytology prep lab. The PGY-5 should begin to have an understanding of the role of the practitioner in an integrated health care delivery system and to be aware of the issues in health care management facing patients and physicians. Time permitting, they will participate in Quality Assurance activities, and understand the importance of such activities in the cytopathology lab. 

Based on the Royal College guidelines and recommendations, following the completion of their cytopathology rotations, CBD residents should be ready for independent sign out.

 

MEDICAL EXPERT/CLINICAL DECISION-MAKER

General requirements

  • Demonstrate diagnostic skills for accurate and timely diagnosis of gynecological and non-gynecological cytopathology specimens (EPAs: C#12)
  • Access and apply relevant information to clinical practice (EPA: TTD#2, F#3)
  • Demonstrate effective consultation services with respect to referral in consultation cases (EPAs: C#12, TTP#1).

Specific requirements

  • Demonstrate knowledge of the required elements for specimen identification during submission of a cytologic sample (i.e. multiple unique patient identifiers, specimen type, submitting physician, etc.) as well as specimen acceptance and rejection criteria (EPAs: TTD#1, C#11).
  • Demonstrate knowledge and familiarity with the methods of collection, handling, storage, stabilization, transportation and archival retention of cytology specimens (EPAs: C#1, C#11).
  • Demonstrate understanding of cytopreparatory processing (pre-slide production, slide production and staining) for common cytology preparations including cell block production (EPA: C#11).
  • Demonstrate knowledge of sampling and preparation methods for conventional smears and liquid-based preparations for cervicovaginal cytology (EPA: C#11).
  • Demonstrate knowledge of provincial/territorial management guidelines tailored to the Bethesda System classification for abnormal cervical cytology reporting (EPA: C#12).
  • Demonstrate knowledge of the criteria for adequacy and the current laboratory reporting system (such as negative, inflammatory/reactive, atypical/suspicious, neoplastic or malignant) for fine needle aspiration (FNA) biopsy, including the Bethesda System for reporting thyroid cytopathology and exfoliative non-gynecologic cytopathology specimens from the various sampled body sites such as respiratory tract, urine and bladder washings, pleural, pericardial and peritoneal fluids, peritoneal washings, cerebrospinal fluid, gastrointestinal tract, breast, thyroid, salivary gland, lymph nodes, liver, pancreas, kidney and adrenal gland, ovary and soft tissue (EPA: C#12).
  • Demonstrate knowledge of specimens/situations requiring expedited reporting (critical diagnoses in cytopathology) (EPA: C#12).
  • Demonstrate knowledge of the professional requirements, roles and responsibilities of the medical director of the cytopathology laboratory, head of cytopathology, associate/consultant pathologists, supervisory cytotechnologist, cytotechnologist, medical laboratory assistants and laboratory manager/supervisor (EPA: C#14, TTP#1, TTP#2).
  • Demonstrate knowledge of how to assess cytopathology specimens for cellular interpretation/diagnosis from different sites, comprehensively taking into consideration the specimen type and the sampling method used (EPAs: C#11, C#12).
  • Demonstrate knowledge of HPV testing in cervical cancer screening programs including specimen acquisition and testing methodologies (EPAs: C#11, C#12).
  • Demonstrate knowledge of the application of ancillary techniques to cytological specimens including immunocytochemistry, flow cytometry, and molecular studies (FISH; PCR) (EPAs: C#9, C#10).
  • Demonstrate the knowledge to rapidly evaluate FNA biopsy specimens during ROSE (Rapid On Site Evaluations) from different sites, including determination of specimen adequacy and the need for triage for ancillary techniques, and the appropriate collection of materials for such techniques (EPA: C#11).
  • Demonstrate general knowledge of superficial FNA biopsy procedures, including appropriately taking a history, procuring the specimen, and preparing and staining the smears, with preliminary interpretation of the smears and collection of diagnostic materials with proper handling for ancillary techniques (EPAs: C#9, C#10, C#11, C#12, TTP#1).
  • Demonstrate the ability to compose clear, concise and comprehensive cytopathology reports for specimens from various body sites based upon the final diagnostic findings (EPAs: C#11, C#12, TTP#1).
  • Demonstrate knowledge of the principles of automated screening and screening assist devices for gynecologic cytopathology specimens (EPA: C#11).
  • Demonstrate knowledge of quality control, quality assurance and quality improvement including workload limit guidelines, prospective rescreening, retrospective rescreening, cytohistologic correlations, materials retention requirements, monitoring of turnaround time, diagnostic rates, false negative proportion, etc (EPAs: C#11, C#15, TTP#3)

Communicator

General Requirements

  • Consult effectively with other cytopathologists, cytotechnologists and other members of the team (EPAs: C#12, TTP#1)
  • Establish effective relationships with consulting physicians and surgeons (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Discuss appropriate information with the health care team, and the patient if necessary (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).

Specific requirements

 

  • Act as consultants to clinical colleagues on the interpretation and relevance of cytological findings, with particular regard to their significance in the management of the patient (EPAs: C#12, TTP#1).
  • Understand the information cytology should provide in a given clinical situation and be able to communicate it effectively in an oral and written form (EPAs: C#12, C#14, C#18, TTP#1, TTP#5, TTP#6).

Collaborator

General Requirements

  • Consult effectively with other physicians and health care professionals (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Contribute effectively to other interdisciplinary team activities (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).

Specific Requirements

  • Utilize experience in clinical medicine and surgery to achieve a sound understanding of the effects of disease and the role of pathology in its management (EPAs: TTP#1, TTP#5, TTP#6).
  • Demonstrate the ability to advise on the appropriateness of obtaining cytological specimens and following examination of these, to advise on further appropriate investigations (EPAs: C#11, C#12, C#14, C#18, TTP#1, TTP#5, TTP#6).

Manager

General Requirements

  • Utilize resources effectively to achieve an accurate diagnosis (EPA: C#17, TTP#4).
  • Allocate finite health care resources wisely (EPAs: C#1, C#9, C#10 C#18, TTP#5).
  • Work effectively and efficiently in a health care organization (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Utilize information technology to optimize patient care, life-long learning and other activities (EPA: C#17, TTP#4).

Specific Requirements

  • List and explain the various potential causes of specimen identification errors in both gynecologic and non-gynecologic cytopathology (EPAs: C#15, TTP#3).
  • List and identify the causes of common preparatory artifacts and explain how to confirm these causes and to manage such problems for quality assurance and diagnostic purposes (EPAs: C#15, TTP#3).
  • List and identify the causes for common specimen contaminants and explain how to confirm these causes and to manage such problems for quality assurance and diagnostic purposes (EPAs: C#15, TTP#3).
  • Explain and demonstrate the proper application of continuous quality assurance and regulatory compliance methods (EPAs: C#15, TTP#3).
  • Explain the importance of correlation of prior and subsequent histopathology with cytopathology cases, both in aggregate for quality assurance purposes and on a case-by- case basis for diagnostic purposes (EPAs: C#12, C#15, TTP#1, TTP#3)
  • Explain and demonstrate the proper prioritization of workflow so that the most urgent cases are processed and examined first (EPAs: C#12, TTP#1)

Health Advocate

General Requirements

  • Identify the important determinants of health affecting patients including screening for cancer (EPAs: C#12, TTP#1).
  • Recognize and respond to those issues where advocacy is appropriate (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).

Specific Requirements

  • As members of an interdisciplinary team of professionals responsible for individual and population health care, the cytopathologist will endeavour to ensure that laboratory practices and test selection are regularly evaluated to determine that they meet these community needs (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).

Scholar

General Requirements

  • Develop, implement and monitor a personal continuing education strategy with respect to cytopathology (EPA: C#17, TTP#4).
  • Critically appraise sources of medical information and recognize the current best sources for research in reporting in cytopathology (EPAs: C#9, C#10, C#15, C#16, TTP#4).
  • Facilitate learning of patients, residents, students and other health professionals (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Contribute to development of new knowledge in cytopathology (EPAs: C#16, C#17, TTP#4).

Specific Requirements

  • In the middle of the rotation, a small research project or case study could be discussed with the rotation supervisor (EPAs: C#16, C#17, TTP#4).

Professional

General Requirements

  • Deliver the highest quality care with integrity, honesty and compassion.
  • Exhibit appropriate personal and interpersonal professional behaviours.
  • Practice medicine ethically consistent with obligations of a physician.
  • Demonstrate the knowledge, skills and attitudes relating to gender, culture, and ethnicity pertinent to cytopathology.

Specific Requirements

  • Act as an appropriate role model for students and others (EPAs: TTP#2, TTP#6).
  • Demonstrate a professional attitude to colleagues, as well as to other laboratory staff (EPAs: TTP#2, TTP#6).
  • Have an appreciation of the crucial role of the cytopathologist in providing quality patient care. This will include knowledge of individual professional limitations and the necessity of seeking appropriate second opinions (EPAs: C#12, TTP#1 TTP#6).

 

Instructional Tools

 

CYTOPATHOLOGY (FOUNDATION with elements of CORE (Introduction block) for PGY2, 1 block, 4 weeks)

PGY2s will spend this time with cytotechnologists in the following Units:

  1. Gynecologic cytology (1 week)
  2. Respiratory cytology and Fine needle aspirate biopsy (FNAB) pulmonary cytology (1 week)
  3. Urinary cytology (1week)
  4. Effusion cytology (1 week)

The PGY2 resident will also be required to:

  • attend a Rapid On-site Evaluation (ROSE)
  • spent time in introduction to the cytology technical/preparation area, spending at least a half day
  • may elect to participate in ASC-cytoconferences to deepen understanding of the above Units

CYTOPATHOLOGY (CORE for PGY3 or 4, 2 blocks, 8 weeks)

PGY3s or PGY4s will spend this time with cytotechnologists in the following Units:

  1. Consolidation of Gynecologic, Respiratory, Pulmonary and Effusion (1 week)
  2. FNA Breast, FNA Lymph node and CSF (1 week)
  3. FNA Salivary gland, FNA thyroid and QA/QC (1 week)
  4. FNA Liver, FNA pancreas and GI (1 week)

The following 4 weeks will be spent at Sign out with Cytopathologists

The PGY4 residents will also be required to:

  • Attend ROSE (Rapid On-Site Evaluations) and/or spend time in the cytology technical/preparation area, to perform assessments to fulfill EPA #11.
  • Participate in ASC-cytoeconferences to fulfill the requirement to participate in five (5) ASC-cytoeconferences by the end of their PGY-4 rotation.

 

 

CYTOPATHOLOGY (TRANSITION TO PRACTICE (CBD cohort) PGY 5, 1 block, 4 weeks)

PGY5s will be responsible for organizing the service, supervising and teaching junior residents and students, and further deepening their knowledge. Time during this block may be spent in reviewing cytopathology cases with a greater degree of independence, independent study, external cytopathology electives, fulfilling any outstanding cytopathology rotation EPAs, or cytopathology QA activities. 

 

EVALUATIONS:

  • Each of the Units in the first 8 weeks of Cytopathology (in PGY2 and first 4 weeks of PGY4) is evaluated with a slide test. A final slide test will be given at the end of the 8 week rotation with the Cytotechnologists.
  • CBD stream residents will be required to fulfill at minimum EPAs C#11, EPAs C#12, TTP#1, TTP#3.
  • The residents are to participate in five (5) ASC-cytoeconferences by the end of their PGY4 cytopathology rotation, and submit their post-econference test answers to the senior/charge cytotechonologist at the end of their rotation.
  • An evaluation form will be completed by the teaching cytotechnologists (charge or senior) and cytopathologists through the one45 system to evaluate the resident’s diagnostic skill, CanMEDS roles and other feedback.
  • All tests, forms and copies of evaluations will be submitted to the director of cytopathology who will complete the summary evaluations for the University.

 

SUGGESTED READING

 

  1. Cibas ES, Ducatman BS. Cytology: Diagnostic Principles and Clinical Correlates, WB Saunders, Edinburgh, 3rd Edition, 2009.
  2. Nayar R, Wilbur DC.  The Bethesda System for Reporting Cervical Cytology: definitions, criteria and explanatory notes. 3nd ed. 2015.
  3. Ali SZ, Cibas ES.  The Bethesda System for Reporting Thyroid Cytopathology: definitions, criteria and explanatory notes. 2nd Edition, Springer 2018.
  4. Rosenthal DL, Wojcik EM, Kurtycz DF. The Paris System for Reporting Urinary Cytology. Springer 2016.
  5. Pitman MB, Layfield LJ. The Papanicolaou Society of Cytopathology System for Reporting Pancreaticobiliary Cytology. Springer 2015.
  6. Faquin WC, Rossi ED. The Milan System for Reporting Salivary Gland Cytopathology. Springer 2018.
  7. Cancer Care Ontario (CCO) follow up of abnormal cervical cytology recommendations at https://www.cancercareontario.ca/en/guidelines-advice/cancer-continuum/screening/resources-healthcare-providers/cervical-screening-guidelines-summary/abnormal-cytology-recommendations
  8. Guidelines from the Canadian Society of Cytopathology (CSC) at http://cytopathology.ca/guidelines/
  1. Canadian Society of Cytopathology Guidelines for Practice & Quality Assurance in Cytopathology, Updated 2019
  2. Guidelines for Review of PAP Smears in the Context of Litigation or Potential Litigation
  3. Recommendations on Screening for Cervical cancer

 

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