cytotechnologists & ultrasound-guided fna _ mecak.pdfdr. frable –instrumental in bringing fna...
TRANSCRIPT
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EVOLUTION IN ACTION:
CYTOTECHNOLOGISTS &
ULTRASOUND-GUIDED FNA
MARY ELLEN CLARK, CT(ASCP)
ADELE O. KRAFT, MD
March 15, 2017
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Conflict of Interest
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No conflict of interest to disclose.
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1. Outline how Cytotechnologist’s role has evolved to include
imaging and procedure assistance in the experience of an
ultrasound-guided FNA (USFNA) service in an academic
Pathology Department setting.
2. Identify the steps necessary for a Cytotechnologist to
become an active part of a USFNA service, making use of
a suggested timeline and available learning resources.
3. Recognize the advantages and challenges of active
Cytotechnologist’s participation in USFNA, from a
Cytotechnologist’s and from a Cytopathologist’s point of
view.
Learning Objectives:
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Topics for Today’s Discussion
I. Background
- The history of FNA at our institution
- Our experience with beginning an USFNA service
- Cytotechnologists role and training in USFNA
II. A taste of what it is like:
- Equipment overview
- Basics of imaging
III. A cytopathologist’s perspective
- Sonographic anatomy
- Working with cytotechnologists
- Interesting cases
- Educational resources4
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Why should
cytotechnologists
get involved in USFNA?
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Changing roles of cytotechnologists
Professional growth
Change of scenery
To make a difference
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Evolution of FNA Service at VCUHS
Dr. Frable – instrumental in bringing FNA cytology to the US
Residents perform the
FNAs at bedside or in the clinics as
requested
Fellows attend deep FNA
procedures in CT,
ultrasound, endoscopy,
bronchoscopy
Cytotech accompanies
a fellow to deep FNAs or
2 cytotechs attend deep FNA if fellow is unavailable
Pathologists perform US-guided FNAs
with assistance
from resident or cytotech
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Pathologist-performed USFNA at VCUHS
US-guided fine needle aspiration of superficial lesions is now performed
by pathologists (since 2011)
US-guided fine needle aspiration of breast and deeper lesions are still
performed by radiologists
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When we started:
One pathologist
One ultrasonographer
One secretary
One CT as a backup for the ultrasonographer
Most FNAs were done in clinics using portable equipment.
(There was no permanent FNA area in pathology.)
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Currently:
Four pathologists
Secretarial support
Multiple cytotechnologists and residents have been trained to assist
Dedicated space for the service:
• Waiting area
• Receptionist area
• 2 exam rooms
• Mini-lab for staining and microscopic examination
(Still bring portable equipment to clinics on request).
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The Cytodiagnosis
Center
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A dedicated space within theanatomic pathology departmentfor Pathologist-performed USFNA
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Reception and Waiting Area
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Exam Room
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Mini-Lab
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The Equipment
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Role of the Cytotechnologist in USFNA
1. Maintaining the cytodiagnosis center
• Inventorying supplies and restocking as needed
• Weekly stain maintenance
• Archiving of images
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Role of the Cytotechnologist in USFNA
2. Setting up for the procedure
• Entering patient information into the ultrasound machine
• Making sure settings on the device are appropriate
• Getting out the supplies that are needed
• Consenting and timeout procedure
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Some of the supplies that need to be within reach for each procedure:
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Role of the Cytotechnologist in USFNA
3. Assisting with the procedure:
• Reassuring the patient
• Handing supplies to the pathologist
• Pulling suction or holding probe during the aspiration
• Labeling the screen with appropriate notations
• Adjusting image parameters, as needed
• Saving appropriate images or cine loops during the procedure
• Holding pressure after the aspiration
• Helping to make smears and staining slides
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Pulling Suction
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Doppler
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Cine
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Role of the Cytotechnologist in USFNA
3. After the procedure:
• Talking with the patient (post-procedure survey)
• Annotating images, measuring lesion
• Disinfecting the equipment and other surfaces
• Cleaning up and preparing the room for next procedure
• Taking material to the main lab for accessioning and processing
• Screening case and reporting results including the procedure notes
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Needle image
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Measurements
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Role of the Cytotechnologist in USFNA
4. Other functions as needed:
• Assessing adequacy
• Patient scheduling
• Reception and patient registration
• Scanning patient documents into electronic chart
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Training Time:• First cytotech was in training for about 6 months and served as the
backup for the US tech (procedures were few and far between at first)
• Timeline was shorter for second CT since there were more procedures
more often
• Began training second CT in Summer 2013, when the US tech would be
leaving
• Spent time one on one with the US technologist learning the equipment
• Watched training videos and read training materials
• Observed procedures for about a month with minimal hands-on
involvement
• Began assisting on procedures for about one month with the guidance of
the previously trained CT
• Since then I have been involved in training 5 other CTs which is very
helpful in reinforcing what you know
• Learning is ongoing though!!
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• Introduce the equipment and supplies and explain the procedure while
there is not a patient to focus on
• Make training videos and printed materials available for self-study
• Allow trainee to observe several actual procedures without expecting
them to contribute
• Ease the trainee into assisting with the procedure by allowing them to
do things they are comfortable with, such as holding pressure after each
pass or staining slides
• After observing several procedures let the trainee set up supplies and
operate the ultrasound machine with an experienced tech near by for
guidance
• Each trainee will be different and will have a different comfort level. It’s
important to make sure they get as much practice and guidance as they
need to feel comfortable and proficient
• The more comfortable the cytotech is with assisting on procedures the
more comfortable and less anxious the patient will be!
Tips for training a cytotech to assist with USFNA:
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Training Cytotechs to assist with USFNA
Involves learning in 4 areas:
• Ultrasound Equipment
• Ultrasound Terminology
• Ultrasound Anatomy
• Assisting with Procedures
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Ultrasound Equipment: what you need to know:
Names and location of various parts and controls
The function of controls and how to use them.
For example:
• Gain
• Depth
• Doppler
• Save image and save cine features
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Transducer
Display Screen
Keyboard
Main Parts
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TGCGain
Depth
SaveDoppler
Main Controls
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Gain
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increases or decreases the brightness of the entire sonogram
DarkToo Little Gain
LightToo Much Gain
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Adequate Gain Setting Look for:
- vascular lumens to be black without any white or grey internal echoes
- Other tissues, like skeletal muscle should have good contrast tones
Gain
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allows stepwise control of the amplification of the returning echoes from different depths
Time Gain Compensation (TGC)
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Theoretical Effects
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TGC
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TGC Effects
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Ultrasound Terminology
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Echogenicity – the extent to which sound waves are reflected
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Describing Echogenicity
Isoechoic – the same echogenicity as reference tissue
Hyperechoic – more echogenic (brighter) than reference tissue
Hypoechoic – less echogenic (darker) than reference tissue
Anechoic- Neither having nor producing echoes (black)
reference
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Patterns of Echogenicity
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Homogeneous - uniform in composition
Heterogeneous - lacks uniformity
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Ultrasound Anatomy
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Thyroid Sonographic Anatomy
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C
SCM
Thy
Trach
LCM
Strap Muscle
V
Esoph
Plats
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Strap Muscle
LCM
Thy
Thyroid Sonographic Anatomy
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Salivary gland Sonographic Anatomy
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Bone Sonographic Anatomy
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Adipose Tissue
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Cyst
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Cytotech Feedback
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CT career: >40 years
Learning: observation, training by other Cytotechnologist
Biggest challenge: working the US machine
Helpful: DVD tutorials, faculty lectures
Suggestions: screen slides from case; more image interpretation training
Overall evaluation: positive, feeling of playing a great role in patient care, best experience in whole career as CT.
Feedback CT1
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CT career: >20 years
Learning: observation, training by other Cytotechnologist and Ultrasound Technician, independent study, videos
Biggest challenge: working the US machine
Helpful: DVD tutorials, faculty lectures
Suggestions: screen slides from case; refresher courses
Overall evaluation: positive, would recommend role for Cytotechnologists
Feedback CT2
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CT career: >20 years
Learning: observation, training by Pathologist and
Cytotechnologist, videos
Biggest challenge: working the US machine,
understanding anatomy
Helpful: DVD tutorials
Suggestions: more formal lectures
Overall evaluation: positive, good skill to have
Feedback CT3
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CT career: 7 years
Learning: observation, hands on training by
another CT
Biggest challenge: getting use to the machine
Helpful: being trained by an experienced CT
Suggestions: none.
Overall evaluation: Nice change of pace. Likes
patient contact.
Feedback CT4
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CT career: 2 years +
Learning: observation, training by another CT
Biggest challenge: learning to operate the machine
Helpful: Practice
Suggestions: None
Overall evaluation: Rewarding and something
different. Helpful to career.
Feedback CT5
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Pathologist’s perspective
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Team building
Skilled professionals
Pathologist extender
Teaching opportunity
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Interesting Cases
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Interesting Case #1
50 year old man, smoker with a history of
multiple lung surgeries for treatment of
blebs. Recently seen in the ER for sudden
onset of hoarseness.
A right parotid mass was noticed on CT.
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Interesting Case # 1
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Interesting Case # 1
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Interesting Case # 1
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Interesting Case # 1
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55-year old male with neck mass noticed by
the patient 2 months previously.
No history of malignancy.
Never smoker, otherwise healthy.
Interesting Case #2
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Interesting Case #2
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Interesting Case #2
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Interesting Case #2
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Interesting Case #2
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42 year-old man
status post bone marrow transplant
presenting with rapidly enlarging
neck mass.
Interesting Case #3
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Interesting Case #3
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Interesting Case #3
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Interesting Case #3
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Interesting Case #3
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Interesting Case #3
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52 year old woman recently diagnosed
with lung adenocarcinoma metastatic to
the brain. A PET CT showed
hypermetabolic lymph node adjacent to
the mandibular angle. Mild bilateral
cervical adenopathy noticed on MRI.
USFNA requested
Interesting Case #4
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Interesting Case #4
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Interesting Case #4
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Interesting Case #4
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Tutorials
WebsitesSonoworld
https://sonoworld.com/Client/Home/Registration.aspx
MedEd Portal
https://www.mededportal.org/publication/9786
AIUM (American Institute of Ultrasound in Medicine)
http://www.aium.org/cme/cme.aspx
Ultrasound Education Resources
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Palpation Guided FNA & USFNAhttp://www.pathologyoutlines.com/topic/cytopathologypgfnageneral.html
http://www.pathologyoutlines.com/topic/cytopathologyusfnageneral.html
SonoSim Ultrasound Training Solution
http://sonosim.com/
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Ultrasound Education Resources
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Thank you.
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