Thanks to this technology tablet technologies could be grouped into: wearable it is possible to navigate into an image pan, zoom-in, tablets, portable tablets and not-portable tablets. By natural interface pictures tablets such as the Apple Ipad i.
In details, the Epson XDesk is an interactive table; some call it a coffee table because you can put anything Investigation of HTA tools to assess the technology on the surface of the table, it works by projections, with As a core aspect is the introduction of the new technol- the very latest technologies on that.
This desk is also ogies for the D-CYT in the Hospital, specific studies of compatible with Bluetooth communication protocol and Health technology assessment should be performed as soon as you put your phone or camera on the surface focused in the new technologies for the digital-cytology.
MP has prepared the based tool we have proposed in [1] for applications in review on the wearable and portable and not portable Tablet technologies tele-pathology. This tool had been proposed before the and is currently caring the experimentation study. EG has reviewed and diffusion of the tablet technologies and was thus con- improved the scientific content and rationale of the manuscript. All authors have read and approved the final manuscript.
Starting from this Published: 30 September tool the investigation will be widened considering also: 1. Further issues relevant to studies of HTA, as from References 1.
Giansanti D, Castrichella L, Giovagnoli : The design of a health technology specific experience of mondial networks of HTA such as assessment system in telepathology. Telemed J E Health , 14 6 Integration of specific studies on HTA over the senior cytopathologists interact with digital cytology? Ann Ist Super Sanita , 46 2 J Telemed Telecare , 13 7 J Telemed Telecare , 14 7 Tablet technologies have been reviewed with the focus to 5.
A HTA specific tool has training for the technician in the biomedical laboratory. Telemed J E Health , 14 8 Possibilities and limitations of the three different 7. Telemed J E Health , List of abbreviations used 13 2 Telemed J E Health , 13 2 Competing interests The authors declare that they have no competing interests. In addition to the previous smears which are prepared at the time of the fine needle aspiration, the rest of the material is usually flushed in a ethanol or formalin-based solution after which the material is centrifuged and a small mini biopsy is created from the concentrated cellular material at the bottom of the tube; this is known as the cell block.
The slides from the cell block are usually stained by a regular Hematoxylin and Eosin HandE stain. These three types of stains are commonly used in different laboratories. Each one of those has its advantages and disadvantages. For example, DQ stain is good for microorganisms, cytoplasm, and background material staining. In the meantime, Papanicolaou stain is more superior for demonstrating the nuclear details, which are the most important and specific in making the diagnosis of malignancy.
The HandE stain combines the advantages of both Papanicolaou and DQ stains and gives the pathologist a chance to evaluate tissue-like stains similar to routine biopsies. Different types of smear preparations are utilized in the cytopathology laboratory, which includes:. Cytocentrifuge smears, which are prepared using the cytocentrifuge method. This method concentrates the material and is especially advantageous when few cells are present in a large amount of fluid, such as pleural or peritoneal fluids.
Centrifuge smears using membrane filters. This method utilizes the use of paper filter with very small pores to trap contaminating material. It is becoming obsolete since the slide cellular morphology is usually compromised.
Monolayer liquid-based cytology. This technology is now the standard method that is used to prepare Papanicolaou smears. The smears are superior to their conventional counterparts and also allow testing for Human Papilloma Virus DNA particles. The last groups of slides are those prepared using the Cellblock technique, as described above.
Those slides are prepared utilizing formalin-fixed paraffin-embedded tissue. The availability of such material provides the pathologist with material that can be used to do special necessary stains. Microorganisms and immunohistochemical stains are the most commonly used. There is still no agreed upon standard for the best aspiration technique in cytopathology. However, all FNA experts agree on one thing, every aspirator have to get comfortable with one method and modify it as more experience is gained.
The bottom line is to get enough diagnostic cells from the area of interest. The gauges of the needles used vary, however, French gauge needles are the most frequent. Whether to use a gun syringe holder or not when negative pressure is utilized, is left for the level of comfort of the aspirator.
Some believe that using the gun provides more control and more cells. Diagram demonstrating the techniques we use to perform FNA. The advantage of this technique is providing a nice thin smear with less crush artifacts enabling the interpreter of optimum cytological morphology to proceed with appropriate triage.
Diagram showing the steps that are used when aspirating a cystic mass. Re-aspiration of cystic lesions while keeping the needle of the first pass inside the mass is a very helpful trick that helps sample the wall of the lesion and believed to increase sensitivity reprinted with permission from Al-Abbadi, Editor, Salivary Gland Cytology: A Color Atlas, Wiley-Blackwell Aspiration using a fine needle gauge range without negative pressure or a syringe.
Aspiration using a syringe and needle without negative pressure. This method allows the aforementioned capillary pressure to push cells in the hub of the needle avoiding the trauma of negative pressure. It is believed that adding the syringe will allow collection of fluids if the lesion turned to be cystic.
Aspiration using a syringe and needle with utilization of negative pressure. The amount of negative pressure varies; however, cm. This is the method that the author uses without a gun and inserting the needle in a circular way to sample the whole area of the lesion. Basically all ancillary studies can be done using cellular material obtained either from exfoliative or FNA technique. These include:. Immunohistochemistry [ Figure 4 ].
Flow cytometry dot blot images from a submental lymph node. The panels on the left side are from the FNA material using the CRAT method and the panels on the right are from the same patient after the node was excised surgically. To have an informative final cytopathology report after doing the procedure and making the appropriate studies to make a specific diagnosis, it is very important that it expresses few important components. It is recommended that a statement describing if the material was adequate to make an interpretation is inserted in the final report.
As mentioned before, the presence of a pathologist or performance of the procedure by a pathologist is highly recommended in order to increase the adequacy rate. A specific diagnosis is always desired when possible. This has to be interpreted so that a second diagnostic approach is necessary. Sometimes descriptive diagnosis and microscopic description of the smears may be helpful for the clinicians to make a therapeutic decision.
For example, if a nipple discharge was submitted on two smears from the clinician's office and sent to pathology department and those smears contained numerous macrophages but no mammary epithelial cells are seen for evaluation. Although no epithelial cells are present in this case, the features are most likely consistent with a benign process since the increased number of macrophages and the lack of epithelial cells.
In this circumstance, writing a simple microscopic descriptive diagnosis is of a great help to the clinician. In certain circumstances a comment is needed to clarify or add some information that may harbor clinical importance.
Sometimes we need to call the clinicians and discuss the case with him either face to face or over the telephone. However, sometimes the material is non-diagnostic or acellular, and this should be conveyed in the final cytopathology report. So careful reading of the final cytopathology report is mandatory so that no misunderstanding or miscommunication can occur.
Sometimes the material is sub optimal due to multiple factors, the most frequent are:. Air drying artifacts leaving the smears for too long before staining. This will sometimes give false impressions of enlargement of the cells and nuclei, which in inexperienced hands may increase the incidence of false positive diagnosis. Marked acute and chronic inflammation.
The presence of marked inflammation sometime obscure diagnostic cellular details. Paying attention to this is very important. A comment in the report indicating that there is marked inflammation obscuring cellular details may be a necessity and this process should always be conveyed to the clinician to make sure that appropriate patient triage is carried out.
Sometime the material contains too many blood elements, especially red blood cells. There is no single feature that is diagnostic of malignancy. It is the constellation of multiple factors that vary depending on the tissue aspirated, the collection technique and the smear preparation method.
It is very important to be aware of these variables before attempting to make a final cytological diagnosis. Ultimately, we are all responsible for providing an accurate cytological diagnosis.
Problems can arise anytime anywhere from the time the patient is seen until the time the final report is transcribed and faxed or sent to the clinician. Trouble shooting is very important to identify problems, which can arise anytime. Diagnostic pitfalls can still occur and are usually due to:[ 92 — 94 ]. Poor collection technique: This can occur when the appropriate slides or containers with appropriate fixatives are not used at the time of the procedure. Poor fixation: This is sometimes seen when there is no experience with cytopathology material preparation and collection.
Communication with your pathologist is recommended. Inflammatory changes: As described before, sometime extensive inflammation may obscure cellular details and prevent appropriate interpretation. To avoid this problem, treating the patient and repeating the procedure afterwards is recommended. Certain changes are induced by these treatment modalities. To decrease the pitfalls from these changes, appropriate and detailed history should be given by clinicians and awareness of the changes by the pathologist should be taken into consideration.
Atypical cellular changes related to hemorrhage, infarction, or necrosis can be problematic. Awareness of these changes by the cytopathologist is very helpful to prevent both false positive and false negative diagnosis. Despite efforts to be as accurate as possible, both false negative[ 95 — 99 ] and positive[ — ] diagnosis can still occur. False negative diagnoses are most commonly related to:. Desmoplasia: This is defined as the presence of fibrosis which is induced by certain tumors due to secretion of fibrogenic materials.
Many tumors can cause fibrosis around the malignant cells. The most notorious are mammary, pancreatic and billiary tree carcinomas in addition to nodular sclerosing Hodgkin's lymphoma. Applying negative pressure and multiple passes during the FNA procedure can help. Well-differentiated tumor cells: Certain tumors are extremely well-differentiated and they resemble their original cells. For example, well differentiated thyroid follicular carcinoma and well differentiated hepatocellular carcinoma can be deceiving.
Awareness of these tumors and appropriate understanding of limitations of cytology is recommended. In these circumstances, making the final diagnosis on tissue sections probably is more appropriate.
Sampling problems: Sometimes the needle is not in the appropriate lesion of interest. This can be resolved by having an experienced aspirator and judicious utilizing of image guidance.
The presence of inflammation, radiation, and chemotherapy changes sometime can be over interpreted. Applying strict cytological criteria in these situations is very helpful. Pregnancy: Pregnancy sometimes can increase cell size in Papanicolaou smears. Awareness by the pathologist and providing appropriate history is recommended.
Contamination: Contamination can occur either through the needle tract or during processing. Awareness of this potential problem and being diligent regarding following the safety protocols between cases is very important and will decrease the impact of this issue. Inflammation and inflammatory changes, radiation and chemotherapy effects sometimes will lead to false positive diagnosis.
Awareness and applying strict criteria after receiving accurate history is the key to avoid this diagnostic trap. The presence of hemorrhage and infarction sometimes induce atypical changes in the cells. Awareness of this issue, which includes the presence of necrotic material and blood elements, should alert the pathologist to avoid false positive diagnosis. Inexperience by the pathologist may induce false positive diagnosis. To eliminate this issue, consultation with other colleagues in the department of pathology is always helpful.
As part of routine quality control and quality assurance in the cytopathology laboratories, it is highly recommended to have two pathologists co-sign any new diagnosis of malignancy. Each organ has its own diagnostic limitation by cytology. However, common examples are provided in this list:. A reactive mesothelial cell versus well differentiated mesothelioma is sometimes difficult. Correlation with the clinical and radiological picture is always helpful. Glandular lesions on Pap smears.
Those are sometimes difficult, and communication with a gynecologist in the same situation to establish a common language and triaging protocols are very helpful.
Breast: Ductal carcinoma in situ versus invasive ductal carcinoma is difficult to do on cytology. In addition, lobular lesions are sometime easily missed on cytology material.
Awareness of these lesions and common language communication with the clinician is very helpful. Respiratory lesions: Small cell carcinomas cells in sputum cytology sometimes are missed due to their small size and marked degeneration.
Well-differentiated carcinomas in general are not easy to diagnosis. Awareness and correlation of the clinical, radiological, and bronchoscope picture is very helpful. Urinary cytology: Low grade transitional cell lesions are difficult to diagnose by urine cytology.
Communication with the urologist and correlation with the cystoscopic picture is of optimum importance. Lymph nodes: The diagnosis of low-grade lymphoproliferative disorders is difficult based on cytology alone.
To eliminate this issue, using the ancillary studies with immunophenotypic analysis either by immunohistochemistry or flow cytometry is very critical. Soft tissue: Low grade neoplasms are sometime difficult. Awareness of the clinical and radiological picture with appropriate sampling and excellent communication with the clinicians is very helpful. Prostate: There is a consensus agreement that FNA of the prostate is not recommended since differentiation between prostatic intraepithelial neoplasia and invasive carcinoma is practically impossible based on cytomorphology alone.
Pancreas: FNA of pancreatic lesions, especially if there is pancreatitis, may give rise to false positive diagnosis. Awareness of the patient's history and the presence of calcification on radiological images are very helpful clues. In addition, cystic neoplasms are difficult to further be specified based on cytological examination alone. Central nervous system: As it is difficult on surgical biopsies, separating low grade gliomas from gliosis is also difficult on cytomorphology.
When screening CSF samples or contents aspirated from brain reservoirs, awareness about tumors that shed cells is very helpful. Utilizing the science of cytopathology whether exfoliative or FNA is cost effective, fast, simple and accurate. Team work emphasizing excellent communication skills is very important between pathologists and clinicians.
All the information about the patient should be given to the pathologist in order to decrease the frequency of pitfalls that were described.
Encouragement of clinical pathologic correlation conferences and tumor boards is very helpful to establish common language and protocols with appropriate guidelines for diagnostic utilization of cytology materials. Source of Support: Nil. Conflict of Interest: None declared. National Center for Biotechnology Information , U. Journal List Avicenna J Med v.
Avicenna J Med. Mousa A. Author information Copyright and License information Disclaimer. Address for correspondence: Dr. E-mail: moc. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.
This article has been cited by other articles in PMC. Abstract This overview is intended to give a general outline about the basics of Cytopathology. Keywords: Cytology, fine needle aspiration. Open in a separate window. Figure 1. Figure 4. Figure 2.
The optimum goal is to reach a definitive diagnosis This objective is the ultimate goal. As a screening tool The success story of utilizing Papanicolaou smears in detecting early precursor lesions of cervical cancer is well known in the developed word. As a follow-up for different diseases Cytological examinations of specimens taken from different sites as a follow-up after establishing the initial diagnosis is a routine procedure. For determination of different prognostic factors in neoplasia diagnosis This is usually achieved as part of staging or using the cytological samples to perform ancillary studies, such as Her-2Neu analysis on breast mass aspirates.
Simple It is well known that getting most cytological samples is simple. Quick The procedure is very quick and diagnostic answers can be provided immediately at the time of procedure, if needed, or within the next hours. Cost effective The cost effectiveness of cytological examination is well documented in the literature, a feature that is becoming very critical given the current high health care costs.
This includes: Gynecological samples: Papanicolaou smears are the first samples that started the exponential revolution of the cytopathology field. Aspiration cytology Different names are used to describe this expanding technique.
This technique has been used from any lesion in the body which includes two major areas: Palpable lesions: Palpable lesions can be targeted by a clinician and preferably by an experienced cytopathologist. Different types of smear preparations are utilized in the cytopathology laboratory, which includes: Direct smears as described above.
Figure 5. Figure 6. These include: Simple special stains such as stains for microorganisms. Figure 3. Adequacy It is recommended that a statement describing if the material was adequate to make an interpretation is inserted in the final report.
Diagnosis A specific diagnosis is always desired when possible. Descriptive diagnosis microscopic description Sometimes descriptive diagnosis and microscopic description of the smears may be helpful for the clinicians to make a therapeutic decision. Comment In certain circumstances a comment is needed to clarify or add some information that may harbor clinical importance. Recommendations Sometimes we need to call the clinicians and discuss the case with him either face to face or over the telephone.
Sometimes the material is sub optimal due to multiple factors, the most frequent are: Air drying artifacts leaving the smears for too long before staining. False negative diagnoses are most commonly related to: Desmoplasia: This is defined as the presence of fibrosis which is induced by certain tumors due to secretion of fibrogenic materials. On the other hand, false positive diagnosis is usually caused by: Pregnancy: Pregnancy sometimes can increase cell size in Papanicolaou smears.
However, common examples are provided in this list: Well-differentiated tumors in particular liver and thyroid adenocarcinomas. Reactive conditions in the CSF have to be interpreted with extreme caution. Frable WJ. Fine-needle aspiration biopsy: A review. Hum Pathol. Integration of surgical and cytopathology: A historical perspective. Diagn Cytopathol. Demay RM.
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