Cytology

[yaah]

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What's the deal with cytology? Is anyone here doing cytology because they actually really like it, or is it because it makes you more competitive? Sometimes I get the sense that the latter is a more common reason to do it. And there have been recent graduates here who do cytology fellowships and then get jobs where they either do no cytology or minimize what they have to do. So this suggests to me that it doesn't really make you more competitive, because they would have hired you anyway.

Personally, I like bronchial washings but that's about it. It seems to me as though cytology should be a great field, and have lots of potential for quick and fast diagnosis, but it kind of fails too much of the time. Sometimes I wish I enjoyed it because there is a huge need (seemingly) for academic cytopathologists. But I just hate FNAs too much.

There are people who actually like cytology, right? A couple of attendings here really like it, but I have yet to meet a resident who really does.

If people don't like it, why don't they like it? For me, it's the FNA part and the lack of architecture on the slide.

 

[Gut Shot]

If I may resurrect a portion of sacrament's classic Pathology Musings thread:

IV. Cytology Is 50% Imagination and 50% Utter Fabrication
a. I have absolutely no choice but to believe this.
b. Previously, I thought that radiologists were the masters of medical B.S. ("This lucency here, see that... squint a little, see it? That's an ectopic kidney.")
c. Radiologists have nothing on cytologists. ("See how these cells here are plump? Plump and dusky and fluffy? That's an ectopic kidney.")
d. BTW, why must everything in medicine be given utterly non-descriptive terms? Nothing in medicine ever looks, feels or sounds like it is described. The hippocampus looks like a seahorse? To who? Somebody on mescaline? "Ground-glass" patterns? "Woody" edema? "Nutmeg" liver? None of these make any sense.

 

[djmd]

What is wrong with nutmeg liver?
Other than no one knows what a nutmeg looks like.
That is like complaining about orphan annie eyes, because you never saw the comic.

Fresh nutmeg, and a nutmeg liver.

(Hey its from the Pathguy, man that site is useful!) 😎


Oh and to respond to Yaah, (being someone who is not doing cyto)
I think people do it and don't like it for the same reason.
It is challenging and difficult.
So doing a fellowship gives you extra skills in dealing with it.
but signing out cyto is dangerous and fraught with pitfalls.

So it is kind of a CYA.
I think it is useful and groups like to have a cyto boarded person for hard cytos. And I think that thinking about morphology can help you with any case, so it improves one's surgical path skills.

But that is just my impression.

 

[yaah]

Yeah, but for the most part "hard cytology cases" have an out: Defer to biopsy, or be vague. Sometimes you can't waffle, like on a fluid where it is vital to the staging, or on a bile duct washing where you can't get a biopsy. But for the most part, if it isn't clearly one thing or another it's "suspicious." It's a lot harder to justify waffling on a biopsy (or especially a resection). Tough urine? Atypical cells. Tough pap smear? ASCUS, cannot rule out high grade. Tough fluid? Marked atypia, suspicious for malignancy.

 

[djmd]

Yeah, but for the most part "hard cytology cases" have an out: Defer to biopsy, or be vague. Sometimes you can't waffle, like on a fluid where it is vital to the staging, or on a bile duct washing where you can't get a biopsy. But for the most part, if it isn't clearly one thing or another it's "suspicious." It's a lot harder to justify waffling on a biopsy (or especially a resection). Tough urine? Atypical cells. Tough pap smear? ASCUS, cannot rule out high grade. Tough fluid? Marked atypia, suspicious for malignancy.

True, but not everything can be ASCUS, atypical, etc...
I think cytopathologists generally don't let themselves go to that without significant thought about other dx. So while it is an out, they can't using it as easily as Radiology does with 'hedges'...

 

[DrBloodmoney]

Gardasil. #1 reason why I wouldn't do it now. (Actually #2 because I think cyto is teh ghey).

 

[deschutes]

I think some people get a high when calling "Positive for malignancy" based on 10 cells.

Cytology would be cool if it weren't for all the negatives.

 

[b&ierstiefel]

Gardasil. #1 reason why I wouldn't do it now. (Actually #2 because I think cyto is teh ghey).

I've thought about this whole Gardasil thing and wondered if this will obviate the need for pap smears altogether in a few decades. Sure, Gardasil will protect women from common papillomaviruses that cause cervical dysplasia but it won't protect women from ALL papillomaviruses that can theoretically cause cervical dysplasia and ultimately, cervical cancer. Furthermore, I think gynecologists will still continue to do pap smears instead of simply assuming that Gardasil is the end all cureall for cervical cancer...at least for the next few decades. Remember, longitudinal studies are ultimately needed to test the actual efficacy (versus theoretical efficacy) of Gardasil in the prevention of cervical cancer. Plus, clinicians are way too paranoid and obsessive-compulsive to do away with screening procedures such as pap smears when they're so simple to do.

 

[CameronFrye]

I've thought about this whole Gardasil thing and wondered if this will obviate the need for pap smears altogether in a few decades. Sure, Gardasil will protect women from common papillomaviruses that cause cervical dysplasia but it won't protect women from ALL papillomaviruses that can theoretically cause cervical dysplasia and ultimately, cervical cancer. Furthermore, I think gynecologists will still continue to do pap smears instead of simply assuming that Gardasil is the end all cureall for cervical cancer...at least for the next few decades. Remember, longitudinal studies are ultimately needed to test the actual efficacy (versus theoretical efficacy) of Gardasil in the prevention of cervical cancer. Plus, clinicians are way too paranoid and obsessive-compulsive to do away with screening procedures such as pap smears when they're so simple to do.

All very true. Plus, even if Gardasil eliminated the need for pap smears, I think most cytopathologists would view that as a positive.

 

[yaah]

Well, anyone above the age of 16 is unlikely to ever get this vaccine, so they will still be getting paps the rest of their life. And because vaccines cause autism, peanut allergies, encephalitis, anxiety, fibromyalgia, crohn's disease, and everything else except a gunshot wound to the chest, lots of people aren't going to be getting them.

Since apparently this vaccine also causes people to drop their inhibitions and become prostitutes because sex is now free of consequences, it also is going to be less utilized.

The only thing it will probably do is provide for a gradual decrease in the % of abnormal pap smears, but that isn't going to eliminate numbers very quickly.

 

[b&ierstiefel]

What's the deal with cytology? Is anyone here doing cytology because they actually really like it, or is it because it makes you more competitive?

I think cytology training can be important because it complements surgical pathology. I think a surgical pathologist with sound cytology training makes that person a better surgical pathologist. I've found the correlations between the cytology and biopsy to be interesting.

 

[yaah]

I think cytology training can be important because it complements surgical pathology. I think a surgical pathologist with sound cytology training makes that person a better surgical pathologist. I've found the correlations between the cytology and biopsy to be interesting.

That's a good point, you do use a lot of the same skills and it does help often to think about things from the other perspective. I still don't have to like it though. 😉 I guess if I could do cytology without the FNA part I would consider it more. I feel like FNA is such a waste of time, you spend so much of your time preparing the stuff, staining the slides, walking to the site, etc.

 

[deschutes]

I feel like FNA is such a waste of time, you spend so much of your time preparing the stuff, staining the slides, walking to the site, etc.

Yeah, but you won't have to have a gym membership no more.

 

[djmd]

I don't know % but a sizable percentage of cytologist are not performing FNAs. It is good to learn, but lots of places pathologists may not be doing FNAs.

 

[PathOne]

sing along now: "Single cell, single cell, single all the wayyyyyyyy".

Personally, I hate cyto with a vengence. Don't know why, but it's really up there on the Hate Board, along with grossing. Perhaps I just haven't seen the light, or more likely, I just find it boooring. Of course, one could argue that looking at gels are equally in the "watching paint dry" category, but somehow that's different, at least for me (then again, I do also hate the whole array of "compas" blots (i.e. Northern, Southern, Western...)

Don't know about volume trends in cyto, but it sounds probable that it's increasing due to more screening programs (which are currently all the rage in Europe especially). And I agree, that the advent of HPV-vaccines really isn't going to change things in the forseeable future. It's just too prevalent right now, and also, remember that it's also found in males, and as they're not getting Gardasil shots, and can't even be properly diagnosed, HPV is likely to be around for the rest of my lifetime.

 

[b&ierstiefel]

That's a good point, you do use a lot of the same skills and it does help often to think about things from the other perspective. I still don't have to like it though. 😉 I guess if I could do cytology without the FNA part I would consider it more. I feel like FNA is such a waste of time, you spend so much of your time preparing the stuff, staining the slides, walking to the site, etc.

Plus, biopsies are getting smaller and smaller it seems so the divergence in "perspective" between reading biopsies and concurrent cytology slides may be shrinking. We have a few cytology certified attendings that I've signed out biopsies with...I find those signouts to be quite interesting because they bring additional insight into how they come to certain conclusions.

As for the FNA matter...I'll have to get back to you on that one. I've only performed one...didn't bother me that much.

 

[ygdrasil]

As a former cytotech (now MSIII) I guess I'll stick my neck out and revive this topic: Cytology = good!

I worked at a university hospital that had a very active FNA service, and I occasionally wondered at the utility of some of the procedures (e.g. needling a breast mass in an old lady that was clinically and radiologically suspicious). But a lot of cytology provided definitive diagnoses/staging in a more cost-effective manner than surgical sampling.

I'm three years out of touch with the industry, but back in my day [rubs arthritic elbow thoughtfully] a urine or a bladder wash, a bronchioalveolar lavage, or a paracentesis were all arguably more cost-effective than biopsying the associated sites.

And we did a lot (like 100/year) of ultrasound-guided endoscopies to get FNAs from pancreatic or biliary masses that would've been a real pain to sample any other way. (And by "we did" I mean we stood by a microscope in the GI lab while the gastroenterologist worked his tail off.)

 

[LADoc00]

one thing to realize is that for most practices, procedures=decreased reimbursement/hour or unit of time.

I think it is VERY inefficient to have pathologists do marrows or needles. When I was doing dozens/day, I would have to introduce myself, explain everything, get the consent signed..HOURS of time per day that is uncompensated AND a nurse could do. Unfortunately pathology is not structured to employ people like NPs or what not help you do this so it is major timesink. I thought long and hard about how to make $ doing procedures and came to conclusion they are "teh suck" all the way around.

That said, a base level of cyto skill is sine qua non, you must have it. If you suck at it, you must do a fellowship in it to bring those skills in line with practical needs.

Sucking at something is the best reason IMO to do a fellowship in it. It is far better to be competent in everything than stellar in say Heme and suck in everything else. That is the nature of path, you cant have holes be they cyto, derm, heme, gyn or neuro.