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One of our facilities keeps using locum radiologists and quite a few of them are doing core biopsies of the thyroid over FNA. Anyone have experience with this?
How many of you totally despise thyroid FNA?! I am one, predominately due to inadequate sampling and secondarily because of follicular processes that are difficult to define. I feel like the evolution of thyroid cytology is now inappropriately the generally accepted means to either "lobectomy versus watchful waiting", which I believe is only appropriate in capable and confident hands. Needless to say, anything that crosses my desk that I'm uncomfortable with gets a very quick "CONSULT" stamp.
Thinking about it, Bethesda says that about 20% of category IV follicular lesions are neoplastic, which require lobectomy to adequately assess. Something about that other 80% of folk with only half of their thyroids left makes me uneasy.
Hey Webb,
What's the issue with cytopath being on its deathbed? I'm considering doing a cytopath fellowship and there seems to be a lot of demand for cytopath fellowship trained folks now in the job market.
My friend working at Quest also mentioned the same thing (how marketable a cytopath fellowship is).
I've seen you post about negatively about cytopath (also LADoc mentioned the same as well I believe) but the demand in the marketplace is very good. So I'm confused.
Hey Webb,
What's the issue with cytopath being on its deathbed? I'm considering doing a cytopath fellowship and there seems to be a lot of demand for cytopath fellowship trained folks now in the job market.
My friend working at Quest also mentioned the same thing (how marketable a cytopath fellowship is).
I've seen you post about negatively about cytopath (also LADoc mentioned the same as well I believe) but the demand in the marketplace is very good. So I'm confused.
f they call you to come access the core, you look at one or two and throw them into formalin for histology.
What do you mean by this? There is no corresponding FNA smear to assess, they just want you to look at the core bx tissue fragments to confirm they are there, or do you actually make a prep from the core bx?
I seriously would not do a cytopath fellowship. There is more going on in cytopath besides the death of gyn cytology. The future of FNA looks very uncertain to me. Our FNA volumes have plummeted over the years. Cores are replacing FNA. All you will see in real life are mediastinal lymph nodes, thyroid and some other sporadic sites. If they call you to come access the core, you look at one or two and throw them into formalin for histology.
There is NO demand in my neck of the woods for cytopath.
Two of the top 4 things pathologists are sued for are cytopath as well according to an article I read. It is a risky field that doesn't pay well. The time commitment for procedures in endoscopy is large and the reimbursement is not good. You are expected to perform magic off of paucicellular specimens. I saw a false positive cytology specimen lead to someone dying where I trained.
I think WEBB is spot on here. I think the walls are slowly closing in on cytopath. This subspecialty is at higher risk for becoming marginalized.
We know what is happening to Paps. You have a situation in which the Pap coexists with a competing test that eventually will take over and to a large degree replace it. I predicted this when I was starting out my career when the landmark article was published which stated that HPV testing was more sensitive and less specific than the Pap at catching high grade dysplasia/cancer. The cytopaths were in a furor but the truth is that this is what you want in a screening test. Furthermore, this drives up colpos which puts more money in the pockets of obgyns...so they are not going to be allied with cytopaths in defending the Pap.
We see other situations in which the cytopath interpretation can be called into question due to competing tests...bile duct brushing FISH and thyroid molecular testing. In the next ten years, I suspect that the landscape in cytopath when it comes down to this will be much evolved than today especially with thyroid FNAs which has become the new Pap smear in terms of volume. The only way this gets curbed is if one day it is exposed that thyroid FNA is not cost effective. Either way, cytopath loses.
With molecular testing, FNAs are shifting more to core biopsies. The only way cytopath wins is if cores are owned by cytopath and there is a paradigm shift in thought— that core biopsies are the new FNA. But in academic places and super specialized places this is a political battle between surg path and cytopath and I have heard of ugly battles that have swung both ways depending on the institution. Cytopath can keep cores though by having touch preps made since noncytopaths hate looking at smears.
This is a watershed moment for cytopath. I’m not a gambler and I don’t have faith that cytopath will win so it is in your best interest not to focus solely or mostly on cytopath as your practice.
I think WEBB is spot on here. I think the walls are slowly closing in on cytopath. This subspecialty is at higher risk for becoming marginalized.
We know what is happening to Paps. You have a situation in which the Pap coexists with a competing test that eventually will take over and to a large degree replace it. I predicted this when I was starting out my career when the landmark article was published which stated that HPV testing was more sensitive and less specific than the Pap at catching high grade dysplasia/cancer. The cytopaths were in a furor but the truth is that this is what you want in a screening test. Furthermore, this drives up colpos which puts more money in the pockets of obgyns...so they are not going to be allied with cytopaths in defending the Pap.
We see other situations in which the cytopath interpretation can be called into question due to competing tests...bile duct brushing FISH and thyroid molecular testing. In the next ten years, I suspect that the landscape in cytopath when it comes down to this will be much evolved than today especially with thyroid FNAs which has become the new Pap smear in terms of volume. The only way this gets curbed is if one day it is exposed that thyroid FNA is not cost effective. Either way, cytopath loses.
With molecular testing, FNAs are shifting more to core biopsies. The only way cytopath wins is if cores are owned by cytopath and there is a paradigm shift in thought— that core biopsies are the new FNA. But in academic places and super specialized places this is a political battle between surg path and cytopath and I have heard of ugly battles that have swung both ways depending on the institution. Cytopath can keep cores though by having touch preps made since noncytopaths hate looking at smears.
This is a watershed moment for cytopath. I’m not a gambler and I don’t have faith that cytopath will win so it is in your best interest not to focus solely or mostly on cytopath as your practice.
Thrombus, I was hoping you would say "FLEE CYTOPATHOLOGY NOW!".
When you do send out a tough cytology case, they call it some ambiguous diagnosis and recommend rebiopsy anyways. You can do that on your own. The best and brightest of cytopathology are NO better than old community pathologist guy or gal.
Not easy to competently signout cytopath with only a few months of training in residency with no sign out privileges.
Not easy to competently signout cytopath with only a few months of training in residency with no sign out privileges.