Anatomic Pathology Program

Cytopathology Rotation

 

Rotation Director:
Catherine S. Abendroth, MD
 
Goals:
  • To learn morphology, diagnostic techniques and reporting for Gynecologic, fluid, and fine needle aspiration specimens.
 
Learning Objectives:
  • See specific objectives for each block in detailed description
 
Requirements:
  • 6 four-week blocks combined with autopsy pathology
  • See specific requirements for each block in detailed description
 
Components:
1.  Self-assessment          
  • See "Evaluation" below
     
2.  Background reading (covered independently by resident)
  • See specific reading requirements for each block in detailed description
     
3.  Practical exposure to cytopathology
  • Preview and participate in sign out of all HMC cytology specimens
  • See specific requirements for each block in detailed description       
     
4.  Didactic learning
  • Weekly one-on-one microscopic teaching sessions, one hour each week, with Cytology Education Specialist
  • Attendance at Cytology Unknowns conference
     
5.  Active learning/teaching activities
  • Review of study set cases
  • Presentation of cases at Surg path unknown conference (Tuesday Noon)
  • See specific requirements for each block in detailed description
 
Method(s) of Evaluation:
  • Residents will be evaluated based on direct observation by faculty
  • After each rotation, residents will be evaluated by faculty in New Innovations
  • Post-test after weeks 8, 16 and 24
  • Checklist to be completed after weeks 8, 16 and 24

Cytology is an integral portion of a resident's training in anatomic pathology. The American Board of Pathology recognizes the importance of this field by including cytopathology on both the written and practical portions of the examination for certification in Anatomic Pathology. Also, effective in 1989, the ABP offers Added Qualification in Cytopathology requiring a primary certificate in AP or AP/CP and a year of full-time fellowship training in cytopathology.

In addition to the requirements for board certification, training in cytopathology is important given the numbers and various types of cytologic specimens seen by pathologists in both private and academic practice. The publicity surrounding Pap smears, which spurred legislative action and demands for stricter accountability of cytotechnologists and pathologists, serves to highlight the importance of training in this field. Cytology also is an engaging discipline that crosses the boundaries of surgical and clinical pathology and provides a different perspective from which to view histologic material. Furthermore, with a trend toward less invasive procedures, fine needle aspiration and even fluid cytology increasingly serves as the primary diagnosis of a malignancy, as well as providing tissue for molecular testing. Thus even non-cytopathologists must be able to interpret cytology reports and understand the indications for and limitations of cytologic diagnosis.

In this residency program, residents seeking certification in AP/CP will complete a minimum 3-block rotation in Cytology. (Additional training in cytology also may be undertaken for those residents seeking certification in anatomic pathology only, to meet 5th year requirements, for Fellows, or for those with a special interest in cytopathology.) The teaching program is set up as three separate blocks with Gyn cytology comprising the entire first block, fluid cytology in the second block, and fine needle aspiration in the third block. To maintain continuity and maximize exposure to as many cases as possible, review of topics already learned is expected in blocks 2 & 3. In addition, even before their formal rotation through cytology, residents are encouraged to examine cellular material obtained from specimens on the autopsy and surgical pathology services using imprint, scrape and needle aspiration techniques and to correlate surgical and autopsy findings with prior cytologic specimens obtained on their patients.

In order to maximize time for learning, the Autopsy and Cytopathology rotations are combined chronologically. On these combined rotations, if the resident is not performing an autopsy, presenting a case, or signing out a case with the Autopsy attending, he/she can preview cytology slides, attend cytology signout, and go on fine needle aspirations. This system requires motivation and self-discipline on the part of the resident to make the best use of time for reviewing slides, reading, etc.

Much of the education in cytopathology is of necessity self-education. The attached curriculum is meant to serve as a guide. Accomplishing the goals set forth in this syllabus is the responsibility of the individual resident with guidance from the attending staff and cytotechnologist education specialist. The core competencies addressed by the specific requirements, and assessed in the end of rotation evaluations, are indicated by PC (Patient Care), MK (Medical Knowledge), PBLI (Practice Based Learning and Improvement), ICS (Interpersonal and Communication Skills), SBP (Systems Based Practice), and P (Professionalism). A Checklist is provided to help the resident document successful completion of goals at the end of each block. Reading assignments are important to provide depth of knowledge above and beyond morphology. Looking through the microscope at unknown cases is imperative; in addition to study sets, the daily gyn and non-gyn cases provide a significant resource. This syllabus is not meant to be all-inclusive, but rather to strike a balance between practical and theoretical applications, with an emphasis on commonly seen specimens. It is expected that this program will evolve over time, along with the interests and expertise of the faculty in this division.
 

Updated:  4/2012 CSA

BLOCK 1 - Weeks 1-4 and 5-8

GOALS

Introduction to Gyn Cytology

  1. A systematic approach to general cellular features (PC, MK)
  2. Specimen types/methods of collection (PC, SBP)
  3. The Papanicolaou stain (PC, MK)
  4. Reporting results (including Bethesda System) & clinical implications (ICS, SBP, P)
  5. Sensitivity (MK, SBP)

Exfoliative Cytopathology of the Female Genital Tract (FGT) (PC, MK)

  1. The normal uterine cervix & hormonal cytology
  2. Benign inflammatory and infectious changes, repair, postpartum, postmenopausal, radiation, folate deficiency
  3. Atypical squamous cells of uncertain significance (ASCUS)
  4. Squamous intraepithelial lesions (including HPV)
  5. Squamous cell carcinoma
  6. Glandular atypias/neoplasms of the FGT- endocervix, endometrium, ovary/fallopian tube, metastatic lesions
  7. Radiation effect and postradiation dysplasia
  8. Vulvar and vaginal cytology
  9. Misc and rare lesions


GYN CYTOLOGY STUDY MATERIALS

Reading List:

  • Cibas, ES, and Ducatman, BS. Cytology Diagnostic Principles and Clinical Correlates, 3rd Ed., 2009.
  • DeMay, RM, The Art and Science of Cytopathology, 1996.
  • Solomon, D, and Nayar, R. The Bethesda System for Reporting Cervical Cytology, 2nd Ed., 2004.

Optional Reading:

  • Koss, LG, Diagnostic Cytology and Its Histopathologic Bases, 4th Ed., 1992. [can get from SFF]
  • Bibbo, M, Comprehensive Cytopathology, 2nd Ed., 1997.

Cytomorphology CD-Roms [can get from SFF]

Microscope Didactic Sessions with SFF – minimum of 1 hour per week

Review of Glass Study Set Slides:

  • Paps

 

PROGRAM

Weeks 1-4 
GYN:

Introduction 
Normal cytology of the uterine cervix 
Hormonal cytology 
The Papanicolaou stain

  • Required Reading:
    • Cibas: pgs 1-19
    • DeMay: pgs 61-74, 120-123
    • Bethesda System: pgs xxi-18
  • Optional Reading:
    • Bibbo: pgs 97-99
    • Koss: pgs 251-313, 1429-1440, 1474-1484

Benign proliferative lesions 
Infectious & inflammatory processes, repair, postpartum, postmenopausal, radiation, folate deficiency

  • Required Reading:
    • Cibas: pgs 19-29
    • DeMay: pgs 109-120, 133-135, 137-138
    • Bethesda System: pgs 21-64
  • Optional Reading:
    • Bibbo: pgs 125-158, 161-178
    • Koss: pgs 314-370, 663-686
  • Weeks 3-4 – Attend signout without previewing slides - daily


Weeks 5-8 
GYN:

Squamous intraepithelial lesions,
Epithelial cell abnormalities: HPV infection, ASCUS,
Squamous cell carcinoma

  • Required Reading:
    • Cibas: pgs 29-44
    • DeMay: pgs 29-36, 139-158, 74-109
    • Bethesda System: pgs 67-119
  • Optional Reading:
    • Bibbo: pgs 178-225
    • Koss: pgs 371-444, 444-485

AGUS, AIS, Adenocarcinoma of the FGT- endocervix, endometrium, ovary/fallopian tube, other
Vulvar and vaginal cytology
Metastatic & rare lesions

  • Required Reading:
    • Cibas: pgs 44-57
    • DeMay: pgs 120-132, 135-137
    • Bethesda System: pgs 123-187
  • Optional Reading:
    • Bibbo: pgs 231-276, 279-288, 291-310
    • Koss: pgs 535-587, 588-616
  • Sign-out:
    • Daily. Review Gyns prior to sign-out. Screen Paps (16 total).
  • Satisfactory Completion of GYN Post-test
  • Complete Checklist

 

BLOCK 2 - Weeks 9-12 and 13-16

GOALS

  1. Familiarity with cytology of Respiratory Tract, Urinary Tract, Gastro-intestinal Tract, Effusions, and CSF
    - Normal cellular elements (PC, MK)
    - Malignant changes and criteria for classification (PC, MK, SBP)
    - Benign/reactive/inflammatory changes (PC, MK)
    - Cytopreparatory techniques (PC, MK, SBP)
    - Consolidate knowledge by teaching others (PBLI, ICS)
  2. Continued study of Gyn cytology

REQUIREMENTS

  1. Attendance at daily Cytology sign-out
    - Review all Gyn and non-Gyn cases prior to sign-out
    - Provide clinical correlation and follow-up, as appropriate
    - Contribute to Study Set collection
  2. Reading assignments and Glass Slide Study Sets
  3. Microscope Didactic Sessions with SFF – minimum 1 hour per week
  4. Learn basic technique of needle aspiration
  5. Observe/assist with cytopreparation (1/2 day Weeks 13-16)
  6. Present cases at Surgical Pathology Unknowns Conference (at least 4 cases)
  7. Complete Checklist

EVALUATION

  1. Written evaluation of rotation by resident on form provided
  2. Complete checklist, have approved by CSA
  3. Satisfactory completion of Fluids Post-Test (Weeks 13-16)


PROGRAM:

Respiratory Tract
Sputum, bronchial brush/wash/lavage, needle aspiration

  • Required Reading:
    • Cibas: pgs 65-98
    • DeMay: pgs 207-250
  • Optional Reading:
    • Koss: pgs 1440-1443, 1455-1457, 1460-1463, 687-864
    • Bibbo: pgs 325-389
  • Glass Slide Sets:
    • Pulmonary
  • Sign-out:
    • Daily review Gyns and non-Gyn prior to sign-out
  • Presentations:
    • Surgical Pathology Unknowns Conference (at least 1 case)

Urinary Tract

  • Required Reading:
    • Cibas: pgs 105-124
    • DeMay: pgs 385-457
  • Optional Reading:
    • Koss: pgs 1444, 1465-1471, 890-1017
    • Bibbo: pgs 445-475
  • Glass Slide Sets:
    • Urines
  • Sign-out:
    • Daily review Gyns and non-Gyn prior to sign-out
  • Presentations:
    • Surgical Pathology Unknowns Conference (at least 1 case)

Gastrointestinal Tract

  • Required Reading:
    • Cibas: pgs 197-216
    • DeMay: pgs 327-377
  • Optional Reading:
    • Koss: pgs 1018-1081
    • Bibbo: pgs 413-440
  • Glass Slide Sets:
    • Abdomen
    • GI
  • Sign-out:
    • Daily review Gyns and non-Gyn prior to sign-out
  • Presentations:
    • Surgical Pathology Unknowns Conference (at least 1 case)

Effusions and CSF

  • Required Reading:
    • Cibas: pgs 129-151, 155-168, 171-193
    • DeMay: pgs 257-316, 427-456
  • Optional Reading:
    • Koss: pgs 1082-1184, 1185-1204
    • Bibbo: pgs 551-616, 477-491
  • Glass Slide Sets:
    • Fluids
    • CSF
  • Observe Cytopreparatory Techniques:
    • arrange with SFF (1/2 day Weeks 13-16)
  • Sign-out:
    • Daily review Gyns and non-Gyn prior to sign-out
  • Presentations:
    • Surgical Pathology Unknowns Conference (at least 1 case)

 

BLOCK 3 - Weeks 17-20 and 21-24

GOALS

  1. FNA Cytology
    - General principles (MK)
    - Technical aspects (PC, MK, SBP)
    - Benign & malignant conditions by body site (PC, MK)
    - Consolidate knowledge by teaching others (PBLI, ICS)
  2. Continued study of Gyn, Respiratory, Urinary, Gastrointestinal Tracts, CSF, & Fluid cytology

REQUIREMENTS

  1. Attendance at daily Cytology sign-out
    - Review all Gyn and non-Gyn cases prior to sign-out; submit list of diagnoses to attending prior to sign-out
    - Provide clinical correlation and follow-up, as appropriate
    - Contribute to Study Set collection
  2. Reading assignments and Glass Slide Study Sets (see below)
  3. Microscope Didactic Sessions with SFF – minimum 1 hour per week
  4. Accompany pathologist on needle aspirates
    - Learn techniques of slide preparation
    - Adequacy screening
  5. Practice needle aspiration and touch prep techniques in clinic, at surgical bench, or at autopsy
    - Contribute 4 cases (normal and/or abnormal tissues) with examples of needle aspiration, touch or scrape preparations, and corresponding tissue sections; review with CSA
  6. Present cases at Surgical Pathology Unknowns Conference (at least 4)
  7. Complete Checklist

EVALUATION

  1. Written evaluation of rotation by resident on form provided
  2. Compete checklist, have approved by CSA
  3. Satisfactory completion of FNA Post-Test (Weeks 21-24)


FINE NEEDLE ASPIRATION STUDY MATERIALS

  • Required Reading:
    • Cibas, ES and Ducatman, BS. Cytology: Diagnostic Principles and Clinical Correlates, 3rd Ed., 2009, Chapters 8-16
    • DeMay, RM. The Art and Science of Cytopathology, Vol. 2, 1996
  • Optional Reading:
    • Koss, LG. Aspiration Biopsy, 2nd Ed, 1992
    • Bibbo, M. Comprehensive Cytopathology, 2nd Ed, 1997, Chapters 25-32
    • Atkinson, BF. Atlas of Diagnostic Cyto­pathology, 1992, Chapters 6-19 [can get from SFF]
    • Layfield, LJ. Cytopathology of Bone and Soft Tissue Tumors, 2002 [can get from SFF]
  • Glass Slide Study Sets:
    • FNA Boxes

 

ADDITIONAL STUDY

GOALS

  1. Reinforce and expand knowledge of Gyn, non-Gyn and FNA cytology
  2. Increase experience with performance of and preparation of fine needle aspirates
  3. Participate in research activities in Cytopathology
  4. Assume greater degree of responsibility and independence in sign-out

REQUIREMENTS

  1. Attendance at daily Cytology sign-out
    - Review all cases prior to sign-out
    - Provide clinical correlation and follow-up, as appropriate
    - Contribute to Study Set collection
  2. Review of Glass Slide Study Sets (in areas of weakness)
  3. Accompany pathologist on needle aspirates
    - Improve skills in slide preparation
    - Adequacy screening
  4. Practice needle aspiration and touch prep techniques in clinic, at surgical bench, or at autopsy
    - Contribute 4 cases (normal and/or abnormal tissues) with examples of needle aspiration, touch or scrape preparations, and corresponding tissue sections; review with CSA
  5. Present cases at Surgical Pathology Unknowns Conference
  6. Participate in research activity (clinical Cytopathology, preparation techniques, ancillary studies, etc.; this is encouraged but not required)
  7. Assume greater independence at sign-out. Granting of this privilege requires unanimous approval by Anatomic Pathology faculty. If two residents with the same level of independent sign-out are on Cytopathology at the same time, they will sign out on alternate days.
    • Independence Level 1: Submit list of diagnoses (as it would appear on report) to teaching physician prior to sign-out. "Drive" sign-out for non-Gyns. Teaching physician present but will offer comments only after you have committed to a diagnosis. Teaching physician responsible for Gyn sign-out.
    • Independence Level 2: Resident responsible for entire sign-out. Teaching physician will not be present. Slides and preliminary reports forwarded to teaching physician for review by 3 pm. Resident and teaching physician sign report (must include statement that teaching physician has reviewed slides).

CYTOPATHOLOGY ROTATION - CHECKLIST

BLOCK 1Microscope didactic sessions with SFF

__________

 
 

Glass slides study sets:

  • Paps

 

__________

 
 Observe Pap staining procedure

__________

 
 Slides screened   (Total)

__________

 
 Post- test

__________

 

   

 Approved
  C.S. Abendroth

    
BLOCK 2Microscope didactic sessions with SFF  
 

Glass slide study sets

  • Respiratory
  • Urines
  • GI
  • Fluids
  • CSF

 

__________
__________
__________
__________
__________

 
 Assist with cytopreparation

__________

 
 Learn FNA technique

__________

 
 Slides screened   (Total)

__________

 
 Conference cases:

C__________
C__________
C__________
C__________

 
 Post-test

__________

 

   

  Approved
  C.S. Abendroth

    
BLOCK 3Microscope didactic sessions with SFF

__________

 
 FNAs attended/performed (#)

__________

 
 Glass slide study sets (List)

__________
__________
__________
__________

 
 Prepare FNA cases for study set

__________
__________
__________
__________

 
 Conference cases:

C__________
C__________
C__________
C__________

 
 Post-test

__________

 

   

  Approved
  C.S. Abendroth