Added Value, Decreased Cost:The Evolving Role of the Cytotechnologistfor Preliminary Screening and Triage ofThyroid AspiratesAngelean L. Wotruba, B.S., C.T., A.S.C.P.,1* Jimmie Stewart III, M.D.,2

Thomas Scheberl, B.S., S.C.T., A.S.C.P.,1 and Suzanne M. Selvaggi, M.D.2

Immediate adequacy assessment for thyroid fine-needle aspirations(FNAs) is standard practice in many cytopathology laboratories. Apathologist is usually present for these time consuming assessments.The purpose of this 5 month study (January 2008–May 2008) wasto show that cytotechnologists can accurately provide the majorityof immediate adequacy assessments for thyroid FNAs, saving bothtime and money for pathologists, clinicians, and patients. The studyconsisted of 167 thyroid nodule FNAs performed in twice weeklythyroid FNA clinics. A comparison was made of the immediateassessments by five participating cytotechnologists and the prelimi-nary and final diagnoses by three pathologists. The cytotechnologistprepared the slides, assessed the air-dried Hema-DiffTM stainedslides for adequacy, and the pathologist viewed the slides remotelyvia real-time video streaming. Results were recorded in an Excelspreadsheet. There was a discordance rate of 1.2% when compar-ing the cytotechnologist’s adequacy interpretation and the patholo-gist’s preliminary diagnosis; both clinically insignificant. By cyto-technologist assessment, 79.0% of the cases were benign and 6.6%were nondiagnostic. 14.4% of the cases were assessed as cellularnodule or neoplastic lesion; all requiring pathologist’s preliminarydiagnosis. Utilizing a cytotechnologist to provide adequacy, insteadof a pathologist, saved $464.10/case (2.38 passes/case) based oncurrent gross technical and professional charges. On the basis ofour findings, cytotechnologists can accurately provide immediateonsite adequacy assessments for thyroid nodule FNAs. Affordingcytotechnologists the opportunity to preliminarily assess FNAs foradequacy also creates a new role in the laboratory. Furthermore,cost-savings are realized for patients and the health care system.Diagn. Cytopathol. 2011;39:896–899. ' 2010 Wiley Periodicals, Inc.

Key Words: thyroid; fine-needle aspiration; cytotechnologist;adequacy assessment

Cytopathologic diagnosis of fine-needle aspirations

(FNAs) of the thyroid gland has become routine clinical

management of thyroid nodules.1 FNA is an accurate

cost-effective method to diagnose nodules, and it has sig-

nificantly reduced the number of unnecessary thyroid sur-

geries.1 FNA can determine the diagnosis of thyroid nod-

ules with a sensitivity of between 65 and 98% and a spec-

ificity of 72 and 100%.1 Most nodules in the thyroid are

benign (69%) with only a small percentage of nodules

diagnosed as malignant (4%).1 Nondiagnostic rates that

vary from 2 to 21%1 are related to the experience of the

aspirator.2 To reduce the nondiagnostic rate, immediate

adequacy assessments/preliminary diagnoses have been

used to determine when an adequate amount of material

has been obtained.2–7 This in turn saves health care dol-

lars by avoiding repeat procedures.8 Currently, a cytopa-

thologic evaluation at the time of aspiration is standard

practice in many cytopathology laboratories, particularly

in academic medical centers.

Some authors believe that any preliminary diagnosis or

assessment should be performed by a pathologist.8 This is

difficult for many hospital laboratories in that it removes

the pathologist from the laboratory for long periods of time.

A reasonable alternative is to have a well-trained cytotech-

nologist provide an immediate assessment with triage to a

pathologist of any patient’s case that is cellular or has any

other neoplastic features. Cytotechnologists are highly

skilled individuals with extensive training in cellular mor-

phology and are well suited to the task of providing on-site

immediate assessments. Enabling cytotechnologists to rou-

tinely provide immediate assessments affords the patholo-

gist time to spend on other tasks, gives the cytotechnologist

a new role in the laboratory, and is a cost saving.

1Department of Cytopathology, University of Wisconsin Hospital andClinics, Madison, Wisconsin

2Department of Pathology and Laboratory Medicine, University ofWisconsin School of Medicine and Public Health, Madison, Wisconsin

*Correspondence to: Angelean L. Wotruba, B.S., C.T., A.S.C.P., Cytopa-thology Laboratory/D4-259d, University of Wisconsin Hospital and Clinics,600 Highland Avenue, Madison, WI 53792. E-mail: awotruba@uwhealth.org

Received 16 December 2009; Accepted 3 June 2010DOI 10.1002/dc.21487Published online 14 October 2010 in Wiley Online Library

(wileyonlinelibrary.com).

896 Diagnostic Cytopathology, Vol 39, No 12 ' 2010 WILEY PERIODICALS, INC.

The University of Wisconsin Cytopathology Section in

conjunction with the Endocrinology Division of Medicine

and the Endocrine Surgery Service provides a ‘‘one-stop

shopping’’ model for the workup and management of

patients with thyroid nodules. The endocrinologists and

their fellows perform the aspirations under ultrasound

guidance, a cytopathologist and/or a cytotechnologist im-

mediately reviews the Hema-DiffTM stained slides, and

the endocrine surgeons are available for evaluation of any

patient determined to possibly need surgery. No definitive

treatment is given until the entire specimen is evaluated;

however, the immediate assessment/preliminary diagnosis

provides critical information that allows appropriate triage

of patients. This study was performed to determine the ac-

curacy of the cytotechnologist as compared to the pathol-

ogist for the immediate adequacy assessment of thyroid

nodule FNAs.

Materials and Methods

All data were collected from January through May 2008 at

a twice weekly endocrine thyroid FNA clinic at the Univer-

sity of Wisconsin Hospital and Clinics, Madison, WI.

Three pathologists and five cytotechnologists were

involved in the project. Ultrasound-guided FNAs of thyroid

nodules were performed by an endocrinologist and/or endo-

crinology fellow. A total of 167 thyroid nodules were

sampled during this time period. The cytotechnologist pres-

ent at the procedure prepared the slides and made two

slides with each FNA pass. One slide was alcohol-fixed for

Papanicoloau staining, and the second slide was air-dried

and immediately stained with Hema-DiffTM stain. Needles

were rinsed in Hanks balanced salt solution for Thin-Prep

processing. Typically, three passes were made into each

nodule, and then the procedure was stopped to allow the

cytotechnologist time to review the air-dried slides for ade-

quacy. The specimen was deemed adequate when a mini-

mum of five to six groups of at least 10 follicular cells and

colloid were present.9 A specimen with fewer than five

groups of follicular cells or an absence of colloid was con-

sidered inadequate or nondiagnostic. This terminology was

used interchangeably. The cytotechnologist recorded their

assessment of the sample and then paged the pathologist on

service who viewed the specimen remotely via real-time

video streaming across the intranet using a high-resolution

camera (Fig. 1). The pathologist gave their adequacy

assessment/preliminary diagnosis and the cytotechnologist

also recorded their assessment. The data were recorded

onto an Excel spreadsheet.

The video-streaming process utilizes an Olympus1

BX41 micrscope and an Olympus1 DP70-72 series digital

12.5 megapixel camera driven by Microsuite 5TM (Soft

Imaging System Corporation, Lakewood, CO) software.

This allows a pathologist at a central laboratory to review

the case in real-time over a secure intranet IP address.

The resolution is set at 1360 3 1024 pixels, allowing

diagnostic features to be easily seen (Fig. 2).

Costs were calculated by adding the gross technical

and professional charges for adequacy assessment. At our

institution the gross charge for a cytotechnologist’s ade-

quacy assessment is $137 per pass until an adequate pass

is obtained. The total charge for an adequacy assessment

with pathologist’s involvement is $332 per pass, until an

adequate pass is obtained.

Fig. 1. A cytotechnologist at the Olympus BX 41 microscope withvideo-streaming workstation transmitting images from a thyroid FNA toa pathologist in the central laboratory. [Color figure can be viewed inthe online issue, which is available at wileyonlinelibrary.com.]

Fig. 2. An example of the image transmitted to the pathologist via videostreaming showing clear features of papillary thyroid carcinoma. [Colorfigure can be viewed in the online issue, which is available at wileyonli-nelibrary.com.]

CYTOTECHNOLOGIST’S EVOLVING ROLE

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Results

A total of 167 thyroid nodule FNAs were included in this

study. The cytotechnologist’s assessment did not agree

with the pathologist’s preliminary diagnosis in only two

cases. The discordance rate was just 1.20% (Table I). Both

discordant cases were clinically insignificant. In one case,

the cytotechnologist’s interpretation was rare atypical cells,

while the pathologist’s preliminary diagnosis was consist-

ent with a benign colloid nodule. In the second case, the

cytotechnologist’s interpretation was nondiagnostic, while

the pathologist’s preliminary diagnosis was consistent with

a benign colloid cyst. In five of the 167 (3.0%) cases the

pathologist’s preliminary diagnoses were discordant with

the final diagnoses (Table II). These cases were also clini-

cally insignificant and merely reflected the reclassification

of a benign diagnosis or unsatisfactory specimen. Some

may argue that these are not even true discordances; there

were no false positives or false negatives in this study.

By cytotechnologist assessment, most nodules (79.0%)

were benign entities including colloid nodules, Hashimo-

to’s thyroiditis, lymphocytic thyroiditis, and thyroid cysts

(Table III). A smaller fraction of nodules (14.4%) were

assessed as atypical or higher. These cases included diagno-

ses of cellular nodule, follicular neoplasm, Hurthle cell neo-

plasm, and papillary carcinoma. As stated previously, these

were the only cases that would require a pathologist’s pre-

liminary diagnosis. Only 6.6% of cases were considered

nondiagnostic by cytotechnologist’s assessment.

The cost incurred for the cytotechnologist’s immediate

adequacy assessment was less than the cost with the path-

ologist’s involvement. Costs were calculated by adding

the gross technical and professional charges for adequacy

assessment. Since the average number of passes to pro-

vide a diagnostic specimen in this study was 2.38 passes,

the cost savings by having a cytotechnologist render ade-

quacy was $464.10 per nodule. There were 145 benign or

nondiagnostic nodules in our study which would have

resulted in a cost savings of $67,294.50. In 2008, our

laboratory provided immediate adequacy on 771 thyroid

nodule FNAs. With an average of 85.7% of these nodules

not requiring pathologist assessment, this would amount

to a total savings of $306,652.68.

Discussion

Cytotechnologists are highly skilled in cytopathologic

morphology and are able to provide adequacy assessments

for thyroid FNAs to ensure that diagnostic samples are

obtained. In this study, adequacy assessments provided by

the cytotechnologists correlated with the preliminary diag-

noses of pathologists in 98.8% of the cases and all discor-

dances were clinically insignificant. Thyroid FNAs have

become part of the standard of care for patients with thy-

roid nodules, thus the demand for their immediate ade-

quacy is increasing. This creates a vital new role for the

cytotechnologists as a preliminary screener for these

specimens.

In our laboratory, cytotechnologists are an integral part

of the endocrinology thyroid clinic. Prior to clinic, the cyto-

technologist reviews the history of each patient and records

all relevant information including past history of thyroid

disease or thyroid cancer, as well as size and ultrasound

characteristics of each thyroid nodule. This information is

then given to the attending pathologist. The cytotechnolo-

gists also provide onsite immediate adequacy assessments

for all thyroid nodule FNAs. When sufficient material has

been collected to render a benign diagnosis, the cytotech-

nologist informs the endocrinologist that no further passes

are required. If the specimen is nondiagnostic, the cytotech-

nologist requests that additional passes be taken until an

adequate sample is obtained. The cytotechnologist is

required to call the pathologist for a preliminary diagnosis

only on those cases that have morphological criteria associ-

ated with an increased chance of malignancy. These fea-

tures include high cellularity, microfollicular arrangements,

Table I. Cytotechnologist Discordant Cases

Casenumber

Cytotechnologistadequacy assessment

Pathologistpreliminarydiagnosis

1 Nondiagnostic Colloid cyst2 Atypical nodule Colloid nodule

Table II. Pathologist Discordant Cases

Case number Preliminary diagnosis Final diagnosis

1 Cellular nodule Colloid nodule2 Colloid nodule Cellular nodule3 Cellular nodule Hashimoto’s thyroiditis4 Colloid nodule Hashimoto’s thyroiditis5 Nondiagnostic Colloid nodule

Table III. Immediate Assessments and Preliminary Diagnoses ofThyroid Nodules

Immediate assessment/preliminary diagnoses

Cytotechnologistnumber ofcases (%)

Pathologistnumber ofcases (%)

Finaldiagnoses

Nondiagnostic 11 (6.6%) 10 (6.0%) 9 (5.4%)Colloid nodule 108 (64.7%) 109 (65.3%) 109 (65.3%)Hashimoto’s thyroiditis 20 (12.0%) 20 (12.0%) 22 (13.2%)Lymphocytic thyroiditis 1 (0.6%) 1 (0.6%) 1 (0.6%)Negative: thyroid cyst 1 (0.6%) 2 (1.2%) 2 (1.2%)Negative: reactivelymph node

2 (1.2%) 2 (1.2%) 2 (1.2%)

Atypical nodulea 1 (0.6%) 0 (0.0%) 0 (0.0%)Cellular nodulea 10 (6.0%) 10 (6.0%) 9 (5.4%)Follicular neoplasma 5 (3.0%) 5 (3.0%) 5 (3.0%)Hurthle cell neoplasma 1 (0.6%) 1 (0.6%) 1 (0.6%)Papillary cancera 7 (4.2%) 7 (4.2%) 7 (4.2%)Total 167 (100%) 167 (100.0%) 167 (100%)

aDenotes immediate assessments that should be viewed by a pathologistfor a preliminary diagnosis whenever possible.

WOTRUBA ET AL.

898 Diagnostic Cytopathology, Vol 39, No 12

Diagnostic Cytopathology DOI 10.1002/dc

nuclear inclusions, etc. A cytotechnologist also may call a

pathologist for an evaluation of any case that they have dif-

ficulty in assessing. The pathologist’s evaluation is accom-

plished rapidly via video-streaming utilizing the NetCam

feature of Microsuite 5TM and ensures the proper triage of

patients to the endocrine surgeons.

It is important to note that no definitive surgical inter-

vention is performed until the final diagnostic report is

issued. Patients are merely triaged to a surgeon for evalu-

ation and scheduled for further pre-op appointments in

the event that the preliminary diagnosis becomes the final

one after review of all case materials. This ‘‘one-stop

shopping’’ model provides access to the appropriate heath

care provider in one clinic visit, eliminating delays in

appropriate patient care and management.

Utilizing a cytotechnologist as a preliminary screener

of thyroid FNAs saves pathologist’s time. The average

time for a pathologist to be present and provide adequacy

assessments on FNAs of thyroid nodules has been

reported as 35–57 minutes.3 In addition, immediate on-

site interpretations of FNAs by pathologists are insuffi-

ciently compensated by Medicare.10 Sending a cytotech-

nologist for immediate onsite adequacy saves time and

money, as illustrated in our study.

Some3,11 have advocated not providing immediate eval-

uations for FNAs, reporting that there is not a significant

enough decrease in the nondiagnostic rate to justify the

procedure time for the staff involved. However, our insti-

tution is academic and the training of house staff is a

major mission. By providing immediate adequacy assess-

ments, we also assist other departments to train their resi-

dents and fellows in the collection of thyroid FNA speci-

mens while ensuring an adequate sample is obtained. In

addition, patient satisfaction is greatest when an FNA is a

‘‘one-stop’’ procedure, obviating the need for a repeat

clinic visit with its incurred costs to the patient and the

healthcare system.

Our study has shown that cytotechnologists can provide

immediate adequacy assessments to nearly the same accu-

racy as a pathologist. This is a new role for many cyto-

technologists, but a role that once they are trained they

should readily accept. We recommend that institutions

routinely provide immediate on-site adequacy for all thy-

roid FNAs and provide the cytotechnologist the opportu-

nity to do so.

Acknowledgments

We thank the Cytopathology staff at the University of

Wisconsin Hospital and Clinics for their assistance with

this study.

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