Liquid-based Rapid Onsite Evaluation of Endobronchial Ultrasound Cytologies

Presentation on liquid-based rapid on-site evaluation (ROSE) for endobronchial ultrasound cytologies, highlighting advantages over smear-based methods.

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Key Takeaways

Liquid-based ROSE offers a time-efficient and reliable alternative to conventional smear-based ROSE.
ROSE is critical for ensuring adequate diagnostic material from minimally invasive lung cancer procedures.
Challenges of traditional ROSE include time demands, personnel needs, and technical smear preparation issues.
The liquid-based method improves sample handling and intraoperative assessment accuracy.
Clinician collaboration enhances the effectiveness of ROSE in clinical settings.

What the video covers

Introduction of Dr. Nicole Anderson Deals and presentation context by Sukriti Buskoda.
Overview of ROSE's role in endobronchial ultrasound-guided transbronchial needle aspiration for lung cancer diagnosis and staging.
Discussion of challenges with conventional smear-based ROSE, including time consumption, personnel requirements, and technical difficulties.
Presentation of a novel liquid-based ROSE approach developed and validated by the authors to address these challenges.
Explanation of the liquid-based method involving collection into cytology-red solution and monolayer preparation for intraoperative interpretation.
Summary of study findings showing liquid-based ROSE’s accuracy in adequacy assessment with some underestimation but no overestimation.
Engagement of clinicians in the ROSE process to improve sample adequacy and diagnostic yield.
Advantages of liquid-based ROSE include time savings, improved sample preservation, and better workflow integration.
Limitations and pitfalls of the liquid-based method are discussed, including false negatives but no false positives.
The presentation includes validation steps, staining processes, and clinical implications for cytopathology practice.

Chapters

What is the main advantage of liquid-based ROSE over conventional smear-based ROSE?

Liquid-based ROSE improves time efficiency, sample preservation, and reduces technical challenges associated with smear preparation, leading to more reliable intraoperative assessments.

Why is ROSE important in endobronchial ultrasound-guided procedures?

ROSE ensures that adequate diagnostic material is obtained during minimally invasive lung cancer procedures, reducing the need for repeat biopsies and enabling timely diagnosis and staging.

What challenges does traditional smear-based ROSE face?

Traditional smear-based ROSE is time-consuming, often requires two lab personnel, involves technical difficulties in preparing well-stained smears, and may not evaluate material needed for ancillary tests during the procedure.

Full Transcript — Download SRT & Markdown

Speaker A

Good afternoon, everyone. Um, I'm Sukriti Buskoda. I'm currently the ASCE Journal Committee Vice Chair. Welcome to yet another month of ASCE Journal Live presentation. Um, today we have Dr. Nicole Anderson Deals. She's currently a PZY3 resident at Geisinger Medical Center, Danville, Pennsylvania. This is going to be the upcoming cytopathology fellow also at the Geisinger Medical Center, and she will come back to follow up complete her anatomic pathology residency following her fellowship. She's also currently a junior member of ASCE Journal Committee.

Speaker A

Pennsylvania this is going to be the upcoming cytopathology fellow also at the Geisinger Medical Center and she will come back to follow up complete her anatomic Pathology residency following her Fellowship she's also currently a junior uh member of ASE Journal

Speaker A

Um, with that, I'm going to hand over to Nicole, but I just have a quick note to make. If you want to ask any questions throughout the presentation, there is a chat box or a question tab through which you can send us your questions, and we—I will moderate the questions towards the end of the session because this is all yours.

Speaker A

you can send us your questions and we I will moderate the questions towards the end of the session because this is all yours thank you Dr pascara so I will be presenting liquid-based rapid on-site evaluation of endobronchial ultrasound

Speaker A

Thank you, Dr. Paskara. So, I will be presenting liquid-based rapid on-site evaluation of endobronchial ultrasound cytologies. This was published in the Journal of the American Society of Cytopathology in the November to December 2022 issue. Uh, we only have one conflict of interest to disclose, um, which is that Dr. Andrew Fisher, who is an author, is an inventor of Celly and cell block technology, and he does receive royalties for that.

Speaker A

cell block technology and he does receive royalties for that and so I would now um like to introduce uh our first author Dr shibai Dr Bai is current is a current fellow of g-u-g-y-n at Massachusetts General Hospital she completed her apcp

Speaker A

And so, I would now, um, like to introduce, uh, our first author, Dr. Shibai. Dr. Bai is a current fellow of G-U-G-Y-N at Massachusetts General Hospital. She completed her APCP residency training followed by a cytopathology fellowship, both at the University of Massachusetts Chan Medical School.

Speaker A

Medical Center so thank you both for joining us Dr Bai and Dr Fisher um our objectives today are to understand the value of Rapid onsite evaluation understand the challenges of roses they are identified by the authors in conjunction with clinicians at their

Speaker A

And we also have joining us, um, the author Dr. Fisher. As I already mentioned, he is the director of cytopathology at Massachusetts Memorial Medical Center. So, thank you both for joining us, Dr. Bai and Dr. Fisher.

Speaker A

liquid-based rows compared to Conventional smear-based rows so we know that endobronchial ultrasound guided transbronchial needle aspiration is emerging as the safest and most efficient way for diagnosis and staging of lung cancer and that the overall goal of Rose is to ensure a patient only

Speaker A

Um, our objectives today are to understand the value of rapid onsite evaluation, understand the challenges of ROSE as they are identified by the authors in conjunction with clinicians at their institution, understand the concept of liquid-based ROSE and the rapid staining processes developed by the authors, in addition to some of the steps of the validation processes which we will discuss.

Speaker A

identified by the authors were to know if the lesion is reached and if it will yield diagnostic material to decide whether ancillary studies will be needed to ensure if the sample has been collected for all of the indicated

Speaker A

Finally, we will be able to describe the advantages and limitations of liquid-based ROSE compared to conventional smear-based ROSE. So, we know that endobronchial ultrasound-guided transbronchial needle aspiration is emerging as the safest and most efficient way for diagnosis and staging of lung cancer, and that the overall goal of ROSE is to ensure a patient only needs one minimally invasive procedure for complete diagnostic evaluation.

Speaker A

cytopathologist and this metric is defined in the paper as accurate diagnosis well we know how important rows can be we also know that there can be significant challenges to performing the procedure one of the challenges of row is that the authors pointed out is that

Speaker A

[Music] The authors work directly with clinicians to identify the indications of ROSE, as this was an essential step to understanding the value of the ROSE procedure. The five indications for ROSE identified by the authors were to know if the lesion is reached and if it will yield diagnostic material, to decide whether ancillary studies will be needed, to ensure if the sample has been collected for all of the indicated ancillary studies, and sometimes to know if the lesion is definitively benign or malignant.

Speaker A

percent of cytotechnologists and 13.5 percent of cytopathologists surveyed reported a typical roast procedure requires more than 45 minutes of time some of the other challenges of Rose described by the authors is that Rose may require two lab Personnel per

Speaker A

Cytotechnologists are able to provide assessment for these first four indications, which the paper defines as accurate adequacy. The fifth indication, an accurate actionable diagnosis, is provided by the cytopathologist, and this metric is defined in the paper as accurate diagnosis.

Speaker A

to be either immediately made into a smear or transferred to a stable rinse solution it is technically challenging to produce a well-preserved and well-stained smear and finally the material in which ancillary tests need to be performed is not evaluated in the actual risk

Speaker A

Well, we know how important ROSE can be. We also know that there can be significant challenges to performing the procedure. One of the challenges of ROSE is, as the authors pointed out, that ROSE is time-consuming. The American Society of Cytopathology's 2019 survey on the use of ROSE found that 86 percent of 261 cytotechnologists and 53.9 percent of 255 cytopathologists surveyed reported a typical ROSE procedure requires more than 30 minutes, while 40.3 percent of cytotechnologists and 13.5 percent of cytopathologists surveyed reported a typical ROSE procedure requires more than 45 minutes of time.

Speaker A

is removed in the Pathology lab and made into a single monolayer preparation that is then interpreted interoperatively similar to reading and Reporting the results of a frozen section so I now have a question for one of the authors Dr Bai what made you realize the

Speaker A

Some of the other challenges of ROSE described by the authors are that ROSE may require two lab personnel per procedure, and reimbursement for ROSE is typically below the cost for a cytopathologist.

Speaker A

you just mentioned um so our UMass had multiple campuses the cytopathologist the center Technologies and the fellows are usually not physically at the size where the Evas procedure were performed and usually so the procedure itself is time consuming and we do require two people

Speaker A

Another challenge noted by the authors is that traditional smear-based ROSE can generate more readings than clinically actionable, and this is due to the material needing to be either immediately made into a smear or transferred to a stable rinse solution. It is technically challenging to produce a well-preserved and well-stained smear, and finally, the material in which ancillary tests need to be performed is not evaluated in the actual ROSE procedure.

Speaker A

know we all know this mirror can we can sometimes it's hard to prepare the it's a quality because of these Blood air dry artifact um so and also this is also important that when we evaluate the smear roles

Speaker A

To address some of the challenges of ROSE, the authors developed and validated a liquid-based approach to ROSE. To generally summarize this liquid-based approach, all material from one site is collected into a cytology-red solution, and then a controlled amount of material is removed in the pathology lab and made into a single monolayer preparation that is then interpreted intraoperatively, similar to reading and reporting the results of a frozen section.

Speaker A

the value of current conventional smear based roles but also can overcome some of these challenges yeah thanks Dr bye thanks Dr bye I'm now going to the briefly describe the message during the ebis procedures the ion a robotic assisted bronchoscopy

Speaker A

So, I now have a question for one of the authors, Dr. Bai. What made you realize the need for a different ROSE method at your institution, or was there something about your department operation that prompted the need for a change?

Speaker A

rinsed in 10 milliliter vials of cider Rich red which is a fixative that lysos and solubilizes red blood cells and serum proteins we'll talk a little bit more about cider Rich lead in a little bit um the clinicians used visual inspection

Speaker A

Muted? I guess unmuted. Oh, sorry. Um, I think, um, we are facing the same challenges as you just mentioned. Um, so our UMass had multiple campuses. The cytopathologists, the cytotechnologists, and the fellows are usually not physically at the site where the EBUS procedure were performed, and usually, so the procedure itself is time-consuming, and we do require two people to keep up the procedure. As we all know, sometimes the collection of the sample can be faster than the ability to prepare, to stain, and to read.

Speaker A

brushing samples when the clinician had the impression that the sample would be informative it would be sent to the Pathology Lab in the Pathology Lab the vials would be visually inspected for turbidity or the present of fine particles if turbid or

Speaker A

Um, so, and also there's a technical challenge in the sense that, you know, we all know this smear can, we can sometimes, it's hard to prepare the quality because of these blood air-dry artifacts. Um, so, and also this is also important that when we evaluate the smear ROSE, um, the ancillary tests that need to be done in the cell blocks are not evaluated during these ROSE during the smear ROSE.

Speaker A

preserved site vial after one to two milliliters of preserved site fluid had been removed a thin prep slide would then be immediately prepared and then stained with a rapid h e procedure using disposable jars the total h e staining

Speaker A

So, all those factors, the challenge will trigger to think about if there's an alternative way to achieve the value of current conventional smear-based ROSE but also can overcome some of these challenges.

Speaker A

receipt of the sample pathology callback time to the proceduralist the amount of specimen removed from the specimen vial and whether the thin prep for the liquid Rose ran dilute accurate adequacy was defined by if the cytotechnologist or cytopathologist

Speaker A

Yeah, thanks, Dr. Bai. Thanks, Dr. Bai. I'm now going to briefly describe the message during the EBUS procedures. The ION, a robotic-assisted bronchoscopy platform, was used in all cases. EBUS or transbronchial needle aspiration was performed with a 21 or 23 gauge Flexion needle. Brushings were performed with the Liberty cytology brush, and brushes were rinsed in saline before additional same-site collection was performed. Material was rinsed in 10 milliliter vials of Cytorich red, which is a fixative that lyses and solubilizes red blood cells and serum proteins. We'll talk a little bit more about Cytorich red in a little bit.

Speaker A

ancillary testing we will discuss this further in the results section for the positive form malignancy cases an adequate reading was deemed accurate when the sample was sufficient for all subsequent necessarily ancillary testing including greater than 200 tumor cells

Speaker A

Um, the clinicians used visual inspection of the vial under clinical judgment to determine if the specimen is adequate. The study defined that the proceduralist would perform a minimum of three needle passes and two brushing samples or a maximum of eight needle passes and four brushing samples. When the clinician had the impression that the sample would be informative, it would be sent to the pathology lab.

Speaker A

case is called inadequate were generally prepared with a second thin prep slide with the lab standard paper nickel outstand if the thin prep did not run dilute the residual material was prepared into a Salient Cell Block in the cases of samples called adequate

Speaker A

In the pathology lab, the vials would be visually inspected for turbidity or the presence of fine particles. If turbid or fine particles are visible, one milliliter or approximately 10 percent of the sample would be removed by pipette. Alternatively, if the sample appeared clear or had few particles, two milliliters would be removed by pipette.

Speaker A

different rapid staining techniques the lab attempted to use diff quick blue to make monolayer preparations from this residual material and through thin prep vials following diagnosis but the stain had variability and generally lacked cytoplasmic to nuclear Contour they also

Speaker A

The pipetted sample would be added to a preserved site vial. After one to two milliliters of preserved site fluid had been removed, a ThinPrep slide would then be...

Speaker A

e validation which was ultimately used in the study first it's worth noting that the eosin was diluted to 10 percent of its original strength for the validation 20 thin prep valves with residual material from FNA samples were prepared into a monolayer slide stained

Speaker A

with h e all cases demonstrated comparable chromatin preservation and display with roughly stoichiometric staining of Chromatin compared to DNA contents transparency groups and cellularity the diagnoses on the 20 cases by h e match the blinded diagnosis of the original paponic allow stain

Speaker A

slide from the original cases in all 20 cases next I'm going to describe the 10 to 20 aliquot validation the material chosen for validation came from leftover material over material in the thin profiles after the cases had been

Speaker A

finalized the case is chosen were ones that had been diagnosed as either negative or positive as previously described based on turbidity of the sample 10 to 20 percent of the remaining sample was removed for creating a monolayer preparation

Speaker A

20 samples were assessed and the diagnosis of the 10 to 20 sample was compared to the final diagnoses for the case it was predetermined that if the 10 to 20 sample was not diagnosable or was falsely negative then the 10 to 20

Speaker A

percent sampling technique would be deemed not valid scoring and diagnosis were done blindly and only the specimen Source given the results showed a hundred percent concordance between 10 and 20 sampling methods in the final diagnosis now we will discuss the results

Speaker A

the first Total 52 liquid-based Rose readings from 30 patients used in the ebus tbna are presented in the study of all 52 readings 28 readings or 53.8 percent were interpreted as adequate in rows with final assessment as adequate

Speaker A

sample 17 cases or 32.7 percent were interpreted as inadequate in rows with final assessment as an adequate sample there were no false positive adequacy readings greetings interpreted as adequate but not actually adequate for ancillary testing there were seven false negative adequacy

Speaker A

readings or 13.5 percent interpreted as inadequate in rows in which the final assessment was actually adequate for a complete diagnosis four of the seven readings from two patients were benign inflammatory necrotizing processes on Final diagnosis three cases for positive

Speaker A

for malignant cells on Final diagnosis molecular testing was requested on only two samples and both had sufficient quantity and quality of DNA and cell blocks for complete Next Generation sequencing using the ion torrent system depicted here is the raw data for

Speaker A

adequacy and preliminary diagnosis by liquid-based Rose in correlation with the final sign out we can see that there were 30 patients in the study and 52 readings the specimen types included mostly fine needle aspirations of nodules or brushings of nodules

Speaker A

there were seven lymph node finetal aspirations four of the seven lymph nodes were inadequate at the time of rows but the final adequacy was adequate the liquid-based rose evaluators included a mix of cytopathologists cytopathology fellows and cytotechnologists here we have some example images of

Speaker A

cases from the study that were positive for carcinoma all the slides were stained with hematoxylin and eosin image a shows three-dimensional tumor cells with waxy cytoplasm and cellular Bridges a finding of squamous cell carcinoma the preparation was made using a 10

Speaker A

aliquot of sample image B is the same case with abundant tumor cells in the Cell Block image C shows two-dimensional tumor cells with intra-nuclear cytoplasmic inclusions a finding consistent with adenocarcinoma image D shows a cell cluster with nuclear

Speaker A

molding highly variable amounts of nuclear material abnormal chromatin and single cell necrosis this was diagnosed as small cell carcinoma of the 23 readings provided with a diagnosis by cytopathologist or cytopathology fellow 13 or 56.5 percent were interpreted as positive for

Speaker A

malignant cells two cases or 8.7 percent were interpreted as negative for malignant cells six cases or 26 percent were interpreted as non-diagnostic and two cases 8.7 percent were interpreted as atypical or definitive benign and definitive malignant cases the sensitivity and

Speaker A

specificity is a hundred percent if atypical is a false negative sensitivity drops to 93 percent and if atypical is a false positive specificity drops to 80 percent figure two highlights a few examples of Rose preliminarily interpreted as atypical or non-diagnostic image a is an

Speaker A

example of one of the two row samples preliminarily called atypical in this example there is subtle hypochromesia of the malignant cell group on the left with benign bronchial cells on the right this was ultimately diagnosed as predominantly lipidic pattern bronchial

Speaker A

alveolar adenocarcinoma image C is an example of the second row sample preliminarily called atypical in image C there is reserve cell hyperplasia from a benign necroinflammatory process this was ultimately interpreted as benign in image B this material was interpreted

Speaker A

as non-diagnostic and was ultimately a benign necroinflammatory process also finally in image D this is a nice example of fungal hyphae which was called adequate and preliminary rows a negative for malignancy on Final diagnosis now to the result now to discuss the

Speaker A

results of time impact of liquid-based rows delivering the sample from the operating room to Pathology Lab took an average of three minutes time from the receipt of the sample in the lab to a reported rows ranged from 6

Speaker A

to 22 minutes with a mean time of 13 minutes median time of 12.5 minutes and a mode of 12.5 minutes moving on now to the discussion a highlight of note is that this is the first study using a liquid-based

Speaker A

cytology method for Rose procedure in which a controlled and measured amount of material was prepared into a thin prep slide stained with a rapid Agony and interpreted also to reiterate the goal of developing liquid-based rows was to achieve the values of smear-based

Speaker A

rows to overcome some of the limitations of smear-based rows and to facilitate estimation of the adequacy at the time of Rose before we get into the further details of the potential time saving aspects of liquid-based rows I wanted to discuss

Speaker A

the goal of facilitating estimation of adequacy at the time of Rose the paper cites the study rapid on-site psychological evaluation during endobronchial ultrasound guided transbronchial needle aspiration for nodal staging in patients with lung cancer published in the annals of

Speaker A

thoracic surgery in 2013 by Dr takahiro Nakajima which found the concordance rate for staging between rows and final pathologic diagnosis was 94.3 percent using conventional smear-based rows in this study when considering cases as benign or malignant if atypical was

Speaker A

considered a false negative the sensitivity of liquid-based Rose is 93 it seems reasonable to consider liquid-based Rose comparable to smear-based rows in terms of sensitivity and specificity so my next question for the authors is do you think that liquid-based Rose at

Speaker A

your institution has attained the goal of facilitating an accurate estimation of adequacy at the time of Rose comparable to smear-based rows I talked about you're muted again okay so I have to control myself sorry again um so the short answer is yes

Speaker A

um I think we're now achieve the goal of accurate estimation of adequacy so back to our all 52 readings um there are 28 Reese um we read on added roles as adequate and all of them concorded as a final

Speaker A

into um there are previous Saturdays um has shown the accurate exclamation of accuracy in long and with the dyno FNA was about 95 using this mirror based Rose so I think we're comparable and I think we're we're pretty good at

Speaker A

estimating the adequacy yeah thank you thank you foreign in the discussion it is mentioned that it is safer to err on the side of calling a benign process inadequate here we can review the situations in which the adequacy of malignant cases

Speaker A

were underestimated liquid-based rows performed well determining the four components of adequacy with some tendency to underestimate adequacy but no overestimation of adequacy in three readings from three patients with malignancy which was 3 of 26 or 12 percent of patients with malignancy in

Speaker A

the study adequacy was underestimated one case which was mentioned as reading 5 patient 3 red immuno read by a Pathologists proved more cellular with immunohistochemistry and the cell block than expected the other two reading 37 patient 21 and reading 38 patient 22

Speaker A

were read by cytotechnologists both with final diagnoses of squamous cell carcinoma upon review both were determined to actually have sufficient material based on the liquid Rose slide consisting of mostly individual squamous cells with abundant necrosis all cases eventually

Speaker A

had greater than 200 cells and greater than 10 percent tumor cells per cell block section the paper describes how most Laboratories and including your laboratory use cell blocks for ancillary testing can you describe question for the authors for the authors how the

Speaker A

liquid-based method creation is on the side of underestimation of tumor cellularity and how this could be beneficial um so um so we um I think majority of our cases um uh we have a good concordance with adequacy we

Speaker A

um I decide to call adequate um and inadequate but as I just mentioned we do have seven cases where we underestimate adequacy um that I think it's safe in the arrow that we tend to underestimate especially in those benign flammatory process

Speaker A

because we do want to make sure the samples well the leader is well sampled to completely exclude a malignant process so in that situation the reader tends to um be on conservative side make sure we got enough sample

Speaker A

um but there are also three malignant case where you know when we look back we review the thing prep the squamous cell carcinoma is put down the individual located with abundant necrotic background so make the reading a little

Speaker A

bit challenging yeah thank you thank you yeah absolutely sure just um basically the the whole concept was that we were uh taking a control demand from the vial and then hopefully loading a thin prep in such a way that it would

Speaker A

run dilute meaning that the entire sample would be deposited on the slide and if you're removing like 10 of the samples you'd see roughly what percentage of the cells you have um so we expected um you know a certain level of

Speaker A

Correspondence in between the number of cells that we're actually seeing on the slide and then the number that we would get in our cell box from that and we we just started out by being a little bit cautious of it and I think we're doing a

Speaker A

follow-up study now to really pin down the relationship between the number of cells you see on that thin prep slide and the number that you're going to see in the thin prep section so I think that we're on pretty accurate

Speaker A

about that estimating the adequacy thank you I'm now going to spend some time describing how this laboratory uses cider Rich red as the collection media for all fnas and non-gynecologic brushing since this may differ from practices in other Laboratories so since

Speaker A

2000 the Performing laboratory has used cider Rich red as the collection media for all fnas and non-gyncologic brushings immunohistochemistry and molecular procedures have all been validated on this platform to be able to use thin prep processing on routine samples the

Speaker A

lab centrifuges material out of cider Rich red and resuspends the sample in preserved site once resuspended most routine FNA and brushing samples have a thin prepared and a Cell Block made if the sample did not dilute or if a sample

Speaker A

has five visible particles so my question for the authors is now um why did you choose to use cyto Rich red instead of cytolite so we've always used instead of Rich red um and since all of our processes are

Speaker A

validated on that that that's what we of course wanted to continue to use so we wouldn't have to validate more but there's a really good reason for using set of Rich red and it is that it um lyses all of the red blood cells

Speaker A

which is a pretty easy thing to do a dilute alcohol solution would also do that cytolight also lyses all the red blood cells but the advantage of cyto Rich red is that all of those sliced red blood cells and all of the serum

Speaker A

proteins inside of rich red do not precipitate out whereas in Satellite you can lyse all of the red blood cells but very quickly all of the proteins that are laced and released from those cells precipitates out so in fact you can do

Speaker A

the experiment it's a kind of a fun one to do if you take like 100 microliters of blood and put it into cellulite you lyse all of the red cells but very quickly a precipitate will form in the

Speaker A

volume of the precipitate will will measure about 100 microliters so you haven't actually accomplished getting rid of the the debris that you don't want to see that's so that that was the whole concept behind selling it I know

Speaker A

we've got a conflict of interest but the whole concept is that we really want just the cells of interest and we want to make sure that we can recover those cells which is what selling it was designed to do

Speaker A

um quantitatively so another major reason that I think if Labs want to adapt this liquid-based Rose I think you should consider using um cider Rich red because since it lyses all of the material if you have a sample that's diluted with

Speaker A

a little bit of blood um you can see how much actual sample you got the blood cells will go away it'll be crystal clear and then you can see the actual particles that are left over that that's going to be the

Speaker A

diagnostic material and so we got the um clinicians really kind of engaged in the process of Rose which is a an interesting thing in itself because if you think of it um cytopathologists who do ultrasound guided fnas they get pretty quickly

Speaker A

feedback over their technique they'll see you know I guess I don't really need that much suction to get a good sample because you'll see that the Spheres that you make that we ourselves will be reading we can see that there's lots of

Speaker A

material on that smear for example or conversely we can you know know that some technique doesn't work very well the clinicians never get that feedback um in rows they kind of do a little bit but the the you know because they're

Speaker A

getting a an answer five minutes later or whatever um after their pass but now they're really directly engaged with that process they look and we have shown them how to look in the container and look is it clear or are there particles

Speaker A

and they can pretty quickly get a sense okay this has got some particles in it or this one doesn't and they can learn and they have learned to adapt their technique they use a slow pull that slow pull on method for minimal amount of

Speaker A

suction to get a minimal amount of blood and so that's been very helpful for them the use of set of Rich red has been really helpful because uh they don't even send a sample until they think that it looks like it's about right

Speaker A

in practice they typically do uh you know if you're in there in the or they're they're giving you a pass about every two or three minutes which is faster than you can actually process them so you end up getting passes when you

Speaker A

don't really need them and by the time you know they're not going to probably stop giving doing passes until they've done three anyway so we thought it really doesn't doesn't pay to actually look at those first few passes a third

Speaker A

pass might kind of ruin the other passes if it had a lot you know too much in The Chronic debris or something like that so um all of this is uh to say that the use of Sarah Rich red gave them the feedback

Speaker A

about when a sample would be adequate and so that's why we like it thank you for explaining yeah I think I think it's really great how much you worked with your procedural is to kind of get feedback about this whole process

Speaker A

that's very interesting foreign so now I'm going to discuss um that the monolayer rose procedure was adopted to allow it to be used on cider Rich red needle rinses making the sample treated treatment identical to all existing protocols an off-label use of

Speaker A

the T2000 thin prep processor by Logic was developed by adding one to two milliliters of cider Rich red to The Preserve site vial and then immediately running the thin prep rather than taking the time to centrifuge in keeping the

Speaker A

sample for 15 minutes per the thin prep T2000 protocol the authors noted that this saves about 20 minutes of time I'd now like to discuss some of the advantages of liquid-based Rose over smear-based rows which includes time saving to the Pathology Lab the time

Speaker A

spent ranged from 9 to 22 minutes with a mean of 13 minutes liquid base Rose requires only one individual for the procedure there's minimal training required to perform liquid-based rows and finally liquid-based Rose creates a uniform presentation of cells free from blood

Speaker A

and air trying artifact and also the cells are composed to a defined area of the slide um I have another question for the authors which is um are there any aspects that you think save the most time or were especially

Speaker A

helpful for your instance for your Institute so I think uh overall we benefit all the advantages just to mentioned but you have to choose the most aspect that we benefit from this change is that we are cutting the Personnel from two to one

Speaker A

and also save the whole procedure to 15 um to just 15 minutes so it's it's a really a huge benefit for us because you know we are short of stuff and now we're only sending one person doing procedure

Speaker A

and for the limited time so we can say we can you know have another people doing other routine work so which is a very um good aspect of this procedure than it is to make a good smear and the

Speaker A

triage you know you get this little tiny dot of stuff that you're trying to divide between the the needle rinse and the smear and then trying to make them make a smear without crushing or that that's actually really technically

Speaker A

difficult and um I think you really can't rely on just anybody to do that if you're going to be doing conventional rows but the liquid-based rose is pretty easy to just teach somebody you know it's cloudy take 2ml or 1ml if it's not cloudy take two

Speaker A

MLS push the button on the machine and you get the prep follow-up question since we're talking about the possible advantages of liquid-based rows we noticed that uh your lab started using dot liquid-based rows for the diagnosis of lung cancers

Speaker A

in patients who then have an immediate lung resection for cancer based on the rose diagnosis how's that going so it um it sounds a little bit scary I think at first when you think of it but um I mean this whole liquid-based Rose

Speaker A

uh you know first you have to obviously validate what you're doing before you can even offer this right and that's what we went through these steps of validating first the the actual stain that we were going to be using and then

Speaker A

validating the uh or basically verifying um the 10 to 20 aliquot idea so with that then sort of validated now we're able to offer the test um and um you know based on our years of experience with conventional

Speaker A

rows and then with these next 50 cases now we've done at least uh at least a hundred or more with the liquid-based rows we realized that the pitfall is not a false positive right we don't have false positives

Speaker A

um watch out for the reserve cell hyperplasia that can have a little bit of atypia um especially in those upper um lymph nodes like a station 7 lymph node I think they seem to be get a little bit more dysplastic like changes

Speaker A

in the in that bronchial epithelium that can be a little bit of a pitfall um there's a few pitfalls to be aware of but by and large the problem is is not a false positive it's a false negative

Speaker A

and going back to one of your earlier questions Nicole um I think the the problem that we have with false negatives has to do with the biopsy needles they simply don't get a good sample of benign lesions generally

Speaker A

speaking so it's they're really uh there's a tremendous need for industry or some sort of partnership to get better biopsy needles for these benign lesions I think we would do a much better job we're deliberately not trying to take big chunks of material

Speaker A

which are best suited we think for the cell block so those would be where you might find some of the benign material I think that explains why some of the ones that were not adequate based on the the

Speaker A

small aliquot that we're taking of the fine finest degree finest material in the sample those finest materials are not likely to be the big cross-linked chunks of tissue that that you might get from a benignation so anyway there's

Speaker A

there's a problem with false negatives and if you just take the idea that uh you're going to just be not giving a diagnosis until you're absolutely sure um and when you you look at your results over years of doing conventional rows or

Speaker A

liquid-based rows you realize that that's still you know far more than 50 percent of the time so the glass is a little bit more half full than it is half empty and um the clinicians still need to address what this lesion is and

Speaker A

the only way to do it non-invasively is with cytology and if they don't come up with an answer by cytology if it's a non-diagnostic said logic thing they pretty much have already decided with the patients that they're going to do a wedge resection at

Speaker A

least so that's kind of the backup that you should feel when you're going into if you anybody's going into the um these Road out procedures it's rapid one anesthesia diagnosis and treat Kind of a Funny acronym but that's the one we

Speaker A

use here um are there other I'd be curious if there are other labs doing Road ads because I haven't heard of people reporting that but um at any rate uh moving towards that has been an interesting thing uh we now

Speaker A

have cross-trained all of the staff to do it it involves basically just a technical person to make the prep they can deliver it then to the Pathologists who might be over at this other outside Clinic um which is not our usual clinic this is

Speaker A

why we kind of had to come up with something they can deliver the slide to them and everybody's cross-trained to do these now and so we've done about 20 so far we've had um 16 that have been uh

Speaker A

outright positive 16 out of 20. uh one was considered suspicious and that ended up being a well-differentiated mucinous lipidic pattern BAC I think everybody can appreciate that that's that's a really Bland tumor right it's it looks like kind of normal bronchial epithelium it's

Speaker A

a very flat two-dimensional sheath there's no nuclear variation no hyperchromesia you might see a nuclear uh intranuclear inclusion which is a good tip-off for cancer but you don't always see it um and that's that's a particularly difficult diagnosis the the diagnostic

Speaker A

trait that we've we've learned that we're kind of recognized is that unlike bronchial epithelium where you'll see mixtures of you know some um some goblet cells and some uh uh you know ciliated cells it's very monotonous it's a pure population of New producing

Speaker A

cells so it otherwise looks just like bronchial epithelium anyway that was a suspicious because it was suspicious and they um had consented the patient they also resected that one so 17 resections for Cancer all non-small cell carcinomas um we had one negative I called it

Speaker A

negative because it was dense chronic inflammation they kept sampling and sampling and sampling there's a potential Pitfall because some cancers will have a lot of chronic inflammation around them but they were sampling widely um and that was um and in fact that was

Speaker A

a case that I ended up going into the or because I kind of wanted to know what was going on I wanted to see things um follow up at six months they did not do a resection because we called it we

Speaker A

said we have an explanation for a lesion and it looks benign and follow up after six months has been showing us a slight decrease in the size of that lesion we worked there for lymphoma as well hello we had one non-diagnostic one where they

Speaker A

were clearly in the lesion we clearly didn't see lesional material we just didn't see fibrosis didn't see anything and I called it non-diagnostic and they said well we've consented the patient to take this out they took it out and it was a

Speaker A

um really desmoplastic adenocarcinoma um and that's again that's a problem with the biopsy needle so I think improvements in the biopsy needle will will will make that an easier thing to deal with in the future um and finally there was one other one that

Speaker A

we called negative but they wanted they had the consent of the patient to basically do either a wedge or the lobectomy if it was positive since we called it negative they did only the wedge and the wedge showed that it was a benign lesion I

Speaker A

think that was organizing pneumonia so we've we've basically been very helpful to a lot of patients we cut the the wait time from the time of a diagnosis the first appearance of a nodule to resection went from 123 days

Speaker A

there's lots and lots of visits lots of x-rays you know they wait for the biopsy results they do this they schedule another meeting with anesthesia um it went from 123 down to 76 which still sounds kind of long

Speaker A

but it's still a huge Improvement and patients have been really quite grateful for this service here so we've had a good result with it I think just approach it very carefully used to your expertise that you've gained um I wouldn't rush to liquid rose on

Speaker A

this until you've gotten some experience with liquid Rose and I think if you do liquid Rose you're going to want to change instead of Rich red otherwise you won't really know how much to remove you also won't be able to know

Speaker A

um won't be able to see very much on the slide because there's so much debris I don't know if you've seen this type of thing but if you have a bloody FNA the prepared with satellite you're going to

Speaker A

have mostly debris on the side you're not going to have a lot of cells we wanted to have lots of cells we wanted to represent the whole 10 or 20 of the sample um one uh if I can

Speaker A

keep going for just a second sure uh the Next Generation I think for the rodat procedure we've been um they've been doing the surgery mostly on patients who are uh ostensibly you know stage one not likely to have mediastinal lymph

Speaker A

node involvement um or you know T up to T2 lesions I guess right still stage one but um they want to expand this rapid diagnosis and treatment in one um anesthesia they want to expand it to patients who have either larger tumors

Speaker A

or equivocal findings on pet or CT suggesting possible lymph node involvement so for those procedures this is a little bit getting tricky and it I'm a little bit concerned about it we're doing a little study to figure out if this is uh how feasible this is

Speaker A

but the idea is that we have to be sure that there's not cancer when they do a rose on a mediastinal node so that's a that's another reason you really have to have a lot of material on that you want to have as much of that

Speaker A

sample as you can maybe too thin preps but you certainly don't want to be using satellite for that I don't think because you're going to have mostly debris and you won't be able to make enough thin preps to see much of the sample

Speaker A

um so that's an interesting challenge for us well Dutch for expanding the discussion Dr Fisher um and if anyone else listening if they have experience for ronak or at their institution and want to chime in or sort of just expand on this whole discussion

Speaker A

feel free to um I am nearing the end of the presentation so we we do have time if anyone is you know thinking about kind of what we just talked about please interrupt me um otherwise I'll I'll finish

Speaker A

so now I'm just going to discuss a little uh a few potential drawbacks of liquid-based rows um as discussed in the paper one of which is the cost benefit balance which um may be an issue for some institutions

Speaker A

um in general the supply costs of the laboratory are less favorable liquid-based preparations require purchase of thin prep materials including processor and disposable filters which is an additional cost also um only one reading per site was needed which means that there is only one 88172

Speaker A

a CPT code for liquid-based Rose versus the possibility to build multiple 88177 CPT codes in a conventional Rose procedure thank you and then finally we're going to discuss the limitations of the study first the anesthesia time of smear-based

Speaker A

Rose ebis procedure was not compared with that of liquid-based Rose Evis um the discussion discussion mentions that proceduralist suppression at this institution was that at the time that the time for liquid-based Rose was not problematic um second flow cytometry was not

Speaker A

indicated for any patients so this is kind of admitted that they would be a required adaptation of the workflow or protocol if flocytometry was needed for some of these patients um and with that that's all I prepared for the discussion of this paper does

Speaker A

anyone have any questions or want to continue to discussion about anything thank you so much Nicole that was wonderful presentation and then thank you Dr Fisher and Dr Bai for this wonderfully written article I learned a lot and I have a question from myself

Speaker A

and then there is one question in the chat as well so I was wondering if you are using side to reach red regularly in other kind of specimens as well foreign maybe I can answer that too um so again I have a conflict of

Speaker A

interest with selling it but selling it uh you know has uh pores kind of like a thin prep machine and once the pores are saturated it won't load any more material uh they uh had a clever um use of a of a like they redisperse

Speaker A

everything so that they can add a little bit more but you really can't add very much more after it's gotten saturated so in fact I know people have not particularly thought that the cell blocks are very cellular resilient the reason they're

Speaker A

not cellular I'll state it clear as I can do it it's because cytolite causes a lot of debris to be precipitated and it's a kind of a uh it's not I don't blame anyone for this I mean it's it's

Speaker A

partly a consequence of the way uh hologic and the and the FDA are the way the FDA is set up basically you know they have to give the protocols that they used when they develop selling it and they worked with satellite it's

Speaker A

their product that makes sense um and then at that point the FDA gives them you know um permission to to Market it in a certain way and they have to Market it basically as using satellite um so it's unfortunate and I think just in

Speaker A

general what we're doing with a liquid-based rose we're adapting protocols we're adopting technologies that are out there because they don't quite work perfectly for what we need them to do and selling it on is I think an unfortunate example

Speaker A

of that word um if people could validate the use of cider Rich red they'll see that it gives you a much better sample IHC is not an issue um so it's been it's been quite a learning curve for me the hologic Reps

Speaker A

the field reps are wonderful people but they can't tell you they're not allowed to by the FDA regulation so it brings up a bigger issue about like can the ASE be involved with um you know facilitating people to

Speaker A

validate things otherwise every single lab has to individually validate things it's a little bit too complicated so anyway yesterday which red is an excellent fixative developed by John Maxim down in Florida um super nice guy very very smart uh

Speaker A

clever to be able to find something that doesn't precipitate debris but preserves antigens and gets rid of the red cells really interesting I'm definitely going to take a further look to that we have a comment as well as a question in the

Speaker A

chat uh comment is it's a great paper opinions after application of this method to other types of procedures including GI for example I think he's referring to uh liquid-based rules so Dr Bai is going to be joining us she

Speaker A

was our fellow this was her fellow project by the way she did fabulous job on this uh liquid-based Rose Project and is going to be coming back to us now after a second Fellowship um as I'm attending but we've been we

Speaker A

have actually in this past year when you haven't been with this uh Dr Bai um been using it for other procedures so yeah it's I think it's it's much easier even at the university the universities pathology there um we're able to

Speaker A

um use this more I think it's more effective I really like it I think it's an easier way to do things yeah thank you Dr Fisher for leading this project also thank you Nicole um for presenting this nicely and thank

Speaker A

you um Dr um best coaches so to holding this meeting but it's good to know that it's also expanded to the GI for other service that because as I just said and when I finished my fellowship the main

Speaker A

we're using this mainly for Evas procedure so it's really good to know looking forward to those surveys as well all right and I would like to thank you uh thank the authors again for accepting our invitation and being here and thank you

Speaker A

Nicole for doing a wonderful job uh thank you Joanne for coordinating all this uh we will see you all next month thank you

Topics:liquid-based ROSErapid on-site evaluationendobronchial ultrasoundcytopathologylung cancer diagnosistransbronchial needle aspirationsmear-based ROSEcytology-red solutionsample adequacypathology workflow

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