EVOLUTION IN ACTION:

CYTOTECHNOLOGISTS &

ULTRASOUND-GUIDED FNA

MARY ELLEN CLARK, CT(ASCP)

ADELE O. KRAFT, MD

March 15, 2017

Conflict of Interest

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No conflict of interest to disclose.

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).

The Cytodiagnosis

Center

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A dedicated space within theanatomic pathology departmentfor Pathologist-performed USFNA

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

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

Transducer

Display Screen

Keyboard

Main Parts

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TGCGain

Depth

SaveDoppler

Main Controls

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)

Theoretical Effects

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TGC

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

Patterns of Echogenicity

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Homogeneous - uniform in composition

Heterogeneous - lacks uniformity

Ultrasound Anatomy

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Thyroid Sonographic Anatomy

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C

SCM

Thy

Trach

LCM

Strap Muscle

V

Esoph

Plats

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

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

Pathologist’s perspective

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Team building

Skilled professionals

Pathologist extender

Teaching opportunity

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.

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

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

Interesting Case #3

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Interesting Case #3

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

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

Thank you.

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