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EDITORIAL
CytoJournal 2014,  11:18

Pancreaticobiliary tract cytology: Journey toward "Bethesda" style guidelines from the Papanicolaou Society of Cytopathology


1 Departments of Pathology and Anatomical Sciences, University of Missouri, Columbia, MO, USA
2 Departments of Pathology and Anatomical Sciences, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
3 Departments of Pathology and Anatomical Sciences, University of Chicago, Chicago, IL, USA
4 Departments of Pathology and Anatomical Sciences, Wayne State University School of Medicine, DMC, and Karmanos Cancer Center, Detroit, MI, USA

Date of Submission08-May-2013
Date of Acceptance20-Mar-2014
Date of Web Publication12-Jun-2014

Correspondence Address:
Vinod B. Shidham
Departments of Pathology and Anatomical Sciences, Wayne State University School of Medicine, DMC, and Karmanos Cancer Center, Detroit, MI
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1742-6413.134441

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How to cite this article:
Layfield LJ, Pitman MB, DeMay RM, Shidham VB. Pancreaticobiliary tract cytology: Journey toward "Bethesda" style guidelines from the Papanicolaou Society of Cytopathology. CytoJournal 2014;11:18

How to cite this URL:
Layfield LJ, Pitman MB, DeMay RM, Shidham VB. Pancreaticobiliary tract cytology: Journey toward "Bethesda" style guidelines from the Papanicolaou Society of Cytopathology. CytoJournal [serial online] 2014 [cited 2017 Apr 26];11:18. Available from: http://www.cytojournal.com/text.asp?2014/11/1/18/134441


The current series of articles related to the Papanicolaou Society of Cytopathology (PSC) guidelines for pancreaticobiliary cytology are the product of significant efforts by many experts working on different PSC guidelines committees. [1] The PSC guidelines for cytologic interpretation and reporting of variety of body site specimens have been described previously. [2],[3],[4],[5],[6] These are comparable to the guidelines from the National Cancer Institute for cervical cytology [7] and fine needle aspiration cytology of breast and thyroid. [8],[9] Most of these systems are designed to stratify the risk of malignancy with diagnostic categories for guiding appropriate management algorithms.

The current guidelines [10],[11],[12],[13],[14] follow the strategies comparable to the Bethesda System for Reporting Thyroid Cytopathology. The guidelines not only consider diagnostic categories and criteria, but also attempt to provide details on other aspects including techniques for obtaining specimens, which patient would benefit most from cytologic evaluation, information on ancillary testing, and patient follow-up/management. The scheme addresses the wide spectrum of approaches to acquire diagnostic material for cytopathologic evaluation from a variety of pancreaticobiliary lesions. A six-tiered system is recommended for the standardized nomenclature in pancreaticobiliary cytology. The categories proposed are: Non-diagnostic, negative, atypical, neoplastic (benign or other), suspicious, and positive. [12]
"Atypical" and "suspicious" categories have relatively well reported malignancy risks. [15],[16] Potentially, the most challenging and controversial category is "neoplastic (benign and other)" with the widest range of interpretations. The entities included in this category range from innocuous lesions such as benign cystic neoplasms (serous cystadenoma) to others like pre-malignant mucinous cysts (cystic mucinous neoplasm and intraductal papillary mucinous neoplasm), low-grade well-differentiated neuroendocrine tumors (NETs), and solid-pseudopapillary neoplasms. The premalignant mucinous cysts without unequivocal features of malignancy would fall in this category with very wide management options. [17] The NETs similarly have many challenges with controversies related to their categorical assignment. Due to their malignant potential, some favor these neoplasms be categorized as "malignant." European Neuroendocrine Tumor Society (ENETS) and World Health Organization categorize low and intermediate grades of these as "tumor" or "neoplasm" in the absence of high-grade criteria (>50 mitoses per 50 high power field for NETs of pancreas and >20 mitoses per 10 high power field or Ki-67 index >20% for NETs of other sites). [18],[19] Undoubtedly, the lesions with unequivocal cytological features of either small cell carcinoma or large cell undifferentiated carcinoma belong to the "malignant" category. An increasing trend with incidental NETs in surgically unfit older patients, favors a conservative approach for small NETs as an alternative management strategy. The categories proposed in the current guidelines permit practical flexibility by surgeons in order to assure that conservative strategies may be a better option than the surgery. This would be more confusing if these cases of low grade neoplasms automatically fell in a "malignant" category!

Utilization of ancillary testing including molecular testing in cystic lesions is also addressed in appropriate areas. [13] With input from the guidelines by the National Cancer Center Network (www.nccn.org) and by the multidisciplinary international groups in the field of pancreatology, post cytologic evaluation and management are also covered. [14]

A "triple test" approach similar to that applied for FNA of breast lesions is recommended. Patient management should be determined by correlating the clinical findings in concert with endoscopic, imaging, and cytologic findings. Effective application of such guidelines is heavily dependent on the collaborative, multidisciplinary interactions between endoscopists, pancreaticobiliary surgeons, radiologists, and cytopathologists. The current CytoJournal supplement issue with individual articles [10],[11],[12],[13],[14] covering various areas highlighted above would be a great resource under Open access platform [20],[21] for all involved in the management of pancreaticobiliary lesions.These PSC guideline articles published under Open Access charter may be disseminated by multiple journals/platforms [22],[23],[24],[25],[26] including e-CytoJournal issue http://www.cytojournal.com/browse.asp?sabs=n. [27]


 » Acknowledgment Top


The authors would like to thank Drs. Nora K. Frisch and Yasin Ahmed (cytopathology fellows at Wayne State University School of Medicine/Detroit Medical Center) for their editorial and copy-editing assistance.

 
 » References Top

1.Pancreaticobiliary Guidelines of the Papanicolaou Society of Cytopathology. Available from: http://www.papsociety.org/pscoforum/index.php.[Last accessed on 2014 May 05].  Back to cited text no. 1
    
2.Guidelines of the Papanicolaou Society of Cytopathology for the examination of fine-needle aspiration specimens from thyroid nodules. The Papanicolaou Society of Cytopathology Task Force on Standards of Practice. Diagn Cytopathol 1996;15:84-9.  Back to cited text no. 2
    
3.Guidelines of the Papanicolaou Society of Cytopathology for fine-needle aspiration procedure and reporting. The Papanicolaou Society of Cytopathology Task Force on Standards of Practice. Mod Pathol 1997;10:739-47.  Back to cited text no. 3
    
4.Guidelines of the Papanicolaou Society of Cytopathology for the examination of cytologic specimens obtained from the respiratory tract. Papanicolaou Society of Cytopathology Task Force on Standards of Practice. Diagn Cytopathol 1999;21:61-9.  Back to cited text no. 4
    
5.Papanicolau Society of Cytopathology Practice Guidelines Task Force. Papanicolaou Society of Cytopathology guidelines for educational notes, disclaimers, and similar comments on reports of cervical cytology specimens. Diagn Cytopathol 2003;28:282-5.  Back to cited text no. 5
    
6.Layfield LJ, Elsheikh TM, Fili A, Nayar R, Shidham V, Papanicolaou Society of Cytopathology. Review of the state of the art and recommendations of the Papanicolaou Society of Cytopathology for urinary cytology procedures and reporting: The Papanicolaou Society of Cytopathology Practice Guidelines Task Force. Diagn Cytopathol 2004;30:24-30.  Back to cited text no. 6
    
7.The 1988 Bethesda System for reporting cervical/vaginal cytologic diagnoses: Developed and approved at the National Cancer Institute workshop in Bethesda, MD, December 12-13, 1988. Diagn Cytopathol 1989;5:331-4.  Back to cited text no. 7
    
8.Baloch ZW, Cibas ES, Clark DP, Layfield LJ, Ljung BM, Pitman MB, et al. The National Cancer Institute Thyroid fine needle aspiration state of the science conference: A summation. Cytojournal 2008;5:6.  Back to cited text no. 8
    
9.The uniform approach to breast fine-needle aspiration biopsy. National Cancer Institute Fine-Needle Aspiration of Breast Workshop Subcommittees. Diagn Cytopathol 1997;16:295-311.  Back to cited text no. 9
    
10.Adler D, Schmidt CM, Al Haddad M, Barthel JS, Ljung BM, Merchant NB, Romagnuolo J, Shaaban AM, Simeone D, Pitman MB, Layfield LJ. Clinical evaluation, imaging studies, indications for Cytologic study and preprocedural requirements for duct brushing studies and pancreatic fine needle aspiration: The papanicolaou society of Cytopathology recommendations for pancreatic and biliary cytology. CytoJournal 2014;11, Suppl S1:1.  Back to cited text no. 10
    
11.Brugge WR, DeWitt J, Klapman JB, Ashfaq R, Shidham V, Chhieng D, et al. Techniques for cytologic sampling of pancreatic and bile duct lesions: The Papanicolaou society of Cytopathology Guidelines. CytoJournal 2014;11, Suppl S1:2.  Back to cited text no. 11
    
12.Pitman MB, Centeno BA, Ali SZ, Genevay M, Stelow E, Mino Kenudson M, et al. Standardized terminology and nomenclature for pancreatobiliary cytology: The Papanicolaou Society of Cytopathology Guidelines. CytoJournal 2014;11, Suppl S1:3.  Back to cited text no. 12
    
13.Layfield LJ, Ehya H, Filie AC, Hruban RH, Jhala N, Joseph L, et al. Utilization of ancillary studies in the cytologic diagnosis of biliary and pancreatic lesions: The papanicolaou society of cytopathology guidelines for pancreatobiliary cytology. CytoJournal 2014;11, Suppl S1:4.  Back to cited text no. 13
    
14.Kurtycz DFI, Field A, Tabatabai L, Michaels C, Young Y, Schmidt CM, et al. Post brushing and fine needle aspiration biopsy follow up and treatment options for patients with pancreatobiliary lesions: The Papanicolaou Society of Cytopathology Guidelines. CytoJournal 2014;11, Suppl S1:5.  Back to cited text no. 14
    
15.Chadwick BE, Layfield LJ, Witt BL, Schmidt RL, Cox RN, Adler DG. Significance of atypia in pancreatic and bile duct brushings: Follow-up analysis of the categories atypical and suspicious for malignancy. Diagn Cytopathol 2014;42:285-91.  Back to cited text no. 15
    
16.Layfield LJ, Dodd L, Factor R, Schmidt RL. Malignancy risk associated with diagnostic categories defined by the Papanicolaou Society of Cytopathology pancreaticobiliary guidelines. Cancer Cytopathol 2013; DOI: 10.1002/cncy.21386 http://onlinelibrary.wiley.com/doi/10.1002/cncy.21386/pdf [Last accessed on 2013 May 23, 2014].  Back to cited text no. 16
    
17.Pitman MB, Centeno BA, Daglilar ES, Brugge WR, Mino-Kenudson M. Cytological criteria of high-grade epithelial atypia in the cyst fluid of pancreatic intraductal papillary mucinous neoplasms. Cancer Cytopathol 2014;122:40-7.  Back to cited text no. 17
    
18.Klimstra DS, Modlin IR, Coppola D, Lloyd RV, Suster S. The pathologic classification of neuroendocrine tumors: A review of nomenclature, grading, and staging systems. Pancreas 2010;39:707-12.  Back to cited text no. 18
    
19.Klimstra DS. Pathology reporting of neuroendocrine tumors: Essential elements for accurate diagnosis, classification, and staging. Semin Oncol 2013;40:23-36.  Back to cited text no. 19
    
20.Frisch NK, Nathan R, Ahmed YK, Shidham VB. Authors attain comparable or slightly higher rates of citation publishing in an open access journal (CytoJournal) compared to traditional cytopathology journals-A five year (2007-2011) experience. Cyto Journal 2014;11:10.Available from: http://www.cytojournal.com/text.asp?2014/11/1/10/131739.  Back to cited text no. 20
    
21.Open Access Explained! Available from: http://www.youtube.com/watch?v=L5rVH1KGBCY.[ Last accessed on 2014 May 05].  Back to cited text no. 21
    
22.Adler D, Max Schmidt C, Al-Haddad M, Barthel JS, Ljung BM, Merchant NB, et al. Clinical evaluation, imaging studies, indications for cytologic study, and preprocedural requirements for duct brushing studies and pancreatic FNA: The Papanicolaou Society of Cytopathology recommendations for pancreatic and biliary cytology. Diagn Cytopathol 2014;42:325-32.  Back to cited text no. 22
    
23.Brugge W, Dewitt J, Klapman JB, Ashfaq R, Shidham V, Chhieng D, et al.Techniques for cytologic sampling of pancreatic and bile duct lesions. Diagn Cytopathol 2014;42:333-7.  Back to cited text no. 23
    
24.Pitman MB, Centeno BA, Ali SZ, Genevay M, Stelow E, Mino-Kenudson M, et al. Standardized terminology and nomenclature for pancreatobiliary cytology: The Papanicolaou Society of Cytopathology guidelines. Diagn Cytopathol 2014;42:338-50.  Back to cited text no. 24
    
25.Layfield LJ, Ehya H, Filie AC, Hruban RH, Jhala N, Joseph L, et al. Utilization of ancillary studies in the cytologic diagnosis of biliary and pancreatic lesions: The Papanicolaou Society of Cytopathology guidelines for pancreatobiliary cytology. Diagn Cytopathol 2014;42:351-62.  Back to cited text no. 25
    
26.Kurtycz D, Tabatabai ZL, Michaels C, Young N, Schmidt CM, Farrell J, et al. Postbrushing and fi ne-needle aspiration biopsy follow-up and treatment options for patients with pancreatobiliary lesions: The Papanicolaou Society of Cytopathology guidelines. Diagn Cytopathol 2014;42:363-71.  Back to cited text no. 26
    
27.e-CytoJournal 2014 Supplement- 1: Pancreaticobiliary tract cytology- PSC Guidelines. Available at http://www.cytojournal.com/browse.asp?sabs=n [Page last accessed on 2014 May 05].  Back to cited text no. 27
    

Editorial/Peer Review Statement
The current article is an editorial related to PSC (Papanicolaou Society of Cytopathology) Pancreaticobiliary tract cytology guidelines submitted by the committee members as authors and published directly without peer review after copy-editing. These guidelines were agreed to be published as Open Access articles under Creative Commons Legal Code (http://creativecommons.org/licenses/by/2.0/ ), this intellectual property (IP) to be retained in public domain.



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