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The opportunity to do FISH testing came from one of our cytopathologists, who decided that we had the skills to be competent and it would allow more time for him to perform other tasks. We started with HER2 training for malignant breast and GI cases about a year and a half ago. He first did a presentation which explained what it was and why it’s performed, followed by a presentation of live cases at the immunofluorescent scope. We also watched the preparation process, which is performed by the immuno lab staff (a 3 day process). It is our understanding that there is no standard training or certification, so our pathologist gave us an unknown box of previous cases that he took when he first trained. The four of us cytotechnologists were allowed to work on this set of 15 cases at our own pace and once we passed this to his satisfaction, we started doing counts of live cases, with the pathologist counting right after us. After a few months he felt competent to let us go on our own. He signed off on the documentation for all the cases we trained on for our permanent employment files. Now the cytotechnologists are responsible for counting the cases and entering the data in our computer system. The pathologist signs out all cases and returns all paperwork to us for filing. The pathologist usually doesn’t do a full count unless he feels there is a discrepancy, and then the case will be reviewed together. There is an average of 2 cases per week. All cases are accompanied by an H and E slide. Even though most of the cases are core biopsies or other surgical excisions, since cytotechnologists are trained in cellular morphology, it’s usually not a problem to determine what’s tumor on these H and E slides. On difficult or subtle cases, the techs will consult a cytopathologist to make sure that we have identified the tumor cells correctly before doing the counts on the corresponding FISH slide.
About 6 months after becoming competent, a couple of cytotechnologists did additional training on ALK FISH cases, which are performed on lung adenocarcinomas. We basically went through the same process. The difference is that there are more cell block cases that are evaluated, so it’s often easier for us to identify the tumor. We probably do an average of 4 ALK cases per week.
In addition to the live cases, we are enrolled in CAP proficiency for HER2, which comes to the lab twice a year (5 cases for each event). There is no CAP proficiency for ALK at this time, so our immuno staff performs out own in house testing twice a year.
We have enjoyed this extra responsibility for the added variety in our jobs and it has allowed us to stay busy and retain our staffing even with the drop in pap volumes the last couple of years. This has benefited our department by freeing up time for our pathologists for other duties such as sign out of surgical cases, which continue to increase in volume every year.
I became involved in the cytogenetics laboratory after the Pap smear volume in my cytology laboratory dropped due to clinical recommendations and the increased onset of molecular testing. Due to decreased volume my employer graciously offered cytotechnologists the opportunity to cross-train in other departments within pathology. I chose cytogenetics because of my interest in the genetic basis of disease and the hands on laboratory work involved in tissue culture. In order to become proficient in tissue culture and analyzing karyotypes, I trained for a period of 6 months in the wet lab under the guidance of very experienced cytogeneticists and practiced karyotyping with an extensive in-house teaching collection created for new medical residents and fellows. I was able to utilize my cytology laboratory skills in the wet lab when culturing cells for karyotyping and FISH, as well as my microscopic skills to locate cultured cells that were good candidates for karyotyping and ultimately the diagnosis of disease. During my time in cytogenetics I enjoyed the delicate and very intensive work involved from beginning to end for each case. Taking a single case from culture to karyotyping and finally to diagnosis was very rewarding. Subsequently, when I worked in the cytology lab I was more comfortable in the wet lab and triaging cytology cases for cytogenetic/FISH testing. Working in a much larger cytogenetics laboratory, compared to the cytology laboratory, helped me gain more communication and management skills through interpersonal communication and organization of a large complex work flow. Due to an opportunity in management I did not continue to work in the cytogenetics laboratory but I thoroughly enjoyed my time there and I know that it helped prepare me for my current role at Brigham and Women's Hospital.
Department of Cytopathology
Brigham and Women's Hospital