key: cord-0728704-lktlmkhz authors: Ronchi, Andrea; Pagliuca, Francesca; Zito Marino, Federica; Montella, Marco; Franco, Renato; Cozzolino, Immacolata title: Interventional cytopathology in COVID‐19 ERA date: 2020-07-12 journal: Cytopathology DOI: 10.1111/cyt.12886 sha: df10023aee0dd3498e2da1af61c452e28821ef72 doc_id: 728704 cord_uid: lktlmkhz OBJECTIVE: The dramatic spread of COVID‐19 has raised many questions about cytological procedures performed in and out of the laboratories all over the world. METHODS: We report a heterogeneous series of FNA performed during the period of phase 1 of the lockdown COVID19‐pandemic to describe our experience and measures taken during this period. RESULTS: A total of 48 FNA (ultrasound, computed tomography and endoscopic ultrasound guided) were processed and reported. CONCLUSIONS: Pre‐existing procedures have been modified to allow healthcare professionals to work safely ensuring patients the necessary assistance with samples suitable for cellularity, fixation and staining for an accurate cytological diagnosis. The outbreak of the COVID-19 pandemic, caused by a new coronavirus (SARS-CoV-2) capable of developing severe acute respiratory syndrome (SARS), has strained the whole world. The high contagiousness of the virus has put the various governments and health care systems in considerable distress. Hospitals have undergone a superhuman "tour de force" in many countries. New guidelines and biosecurity measures from disease control and prevention centers have been introduced. In each hospital, elective procedures were deferred while essential clinical services had to be enhanced to reduce the turnout and to allow social distancing. After the initial disorientation and the inevitable management problems, several strategies have been implemented inside the hospitals to continue ensuring health assistance, taking into account the guidelines by World Health Organization (WHO), European Center for Disease Prevention and Control (ECDC) and, in Italy, the Italian National Institute of Health-Istituto Superiore di Sanità (ISS). SARS-CoV-2 appears to be mainly transmitted at the beginning of the incubation period, when affected patients lack symptoms or exhibit non-specific symptoms [2] [3] . Consequently, each patient should be considered potentially infected. The interventional cytopathologists could unawarely be exposed to the virus while performing fine needle aspiration (FNA) through respiratory droplets, touching contaminated objects or having close unprotected contacts with patients. In this view, the Pathology Service of the Vanvitelli University has established some measures to try to contain the infection within its laboratory and to allow cytopathologists to work safely. Among the activities carried out by cytopathologists in our Pathology Service, surely the ROSE and the interventional This article is protected by copyright. All rights reserved cytology with execution of FNA in clinic outpatient represent two of our strengths. We report a heterogeneous series of FNA performed during the period of phase 1 of the lockdown COVID19pandemic, in order to describe our activity and the relative precautionary measures taken during this period. We implemented some specific measures to limit the possibility of infection, according to the different clinical settings and in collaboration with other specialists involved in the procedures. The number of daily procedures was reduced by 30-50% to allow the equipment and surfaces shared with the patient to be properly cleaned and disinfected. Furthermore, a limited number of people was admitted to the procedure room. Patients' temperature was measured and each patient underwent point-of-care serological diagnostic tests before starting each procedure. The procedure rooms were differently ventilated (from 60 L/s to at least 160 L /s per patient) depending on whether the ROSE took place in radiology service (CT-guided FNA) or in endoscopy service (EUS-FNA) 4 . Adequate safety devices (personal protective equipment (PPE)) were worn. Standard medical masks or EU FFP2 were considered mandatory for US, CT and EUS-guided This article is protected by copyright. All rights reserved procedures. Eye protection, water-resistant long-sleeve gown covers, shoe-covers and were also used for each type of procedure. PPE and waste were properly disposed of 5 . The operators washed their hands before and after contact with each patient. Fixation time of Diff Quik staining during the ROSE was extended to 60-90 seconds, while the times of the following staining passes (reagent B and C) were not modified. As for the alcohol-fixed slides subsequently stained by Papanicolaou stain, we used 95% alcohol solutions with fixation times prolonged at least to 30 minutes. Pambuccian has recently declared that ROSE should be performed during the pandemic only if absolutely necessary to ensure the success of the biopsy procedure and with a high protection for the medical team 15 . We have extended the fixation times for Diff Quik stain to 60-90 seconds, in order to maximize the time of exposition of the virus to alcohol 17 . Concerning the alcohol-fixed slides subsequently stained by Papanicolaou stain, we are using 95% alcohol solutions with fixation times prolonged to 30 minutes at least; although this method lowers the yield of the cytological sample, it allows to manage the smears safely. The main artifact is represented by cell distortion due to shrinkage ( Figure 1 ) and the proteinaceous background is dirtier due the presence of debris, but cytological evaluation has never been severely affected in our experience. Importantly, the extended fixation time in Diff Quik reagent A did not determine any artifacts. Regarding the samples suspended in formalin to set up a CB, as formalin inactivates the virus, the only precaution has consisted in the extension of the fixation time to at least 24 hours (figure 2). The pre-analytical phase for FNA samples is extremely important. The management of the cytological material and the use of different technical supports (e.g., vials, additional smears, cytospin slides, LBC slides, FTA-cards, resins) for one ancillary technique rather than another one will also have to take into account the GMPP. The preparation of cell suspensions in PBS or This article is protected by copyright. All rights reserved physiological solution for FC evaluation is performed in order to prevent environmental contamination 18 . All the steps (aliquoting of sample, use of the centrifuge and vortex) for the preparation are carried out under the chemical hood. Our laboratory has chemical hoods with full suction and total expulsion to the outside after HEPA filtration. Furthermore, a post-fixation in formalin is provided, making the preparation of the method reasonably safe. In general, the use of the under-hood set up is intended for all samples that require the use of vortex or cytocentrifuge. All technical personnel dedicated to these procedures have been properly trained and use the appropriate PPE. Obviously, the use of PPE during all these activities is mandatory. After the procedures, the samples are transported to the pathology laboratory inside a bio-box in a secondary container (trans-bag). In our laboratory the technical procedures have been adapted to this new situation. As regard other clinical activities where the cytopathologists are involved, such as multidisciplinary tumour boards, clinicians, surgeons, radiologists and pathologists can share clinical data and imaging of patients using web-based video conferencing tools to discuss about their management. Finally, the COVID-19 pandemic has put hospitals and pathology laboratories in front of an unprecedented situation since the last century. Therefore, many of the pre-existing procedures have been modified and will have to be further modified to allow healthcare professionals to work safely. Certainly, the close collaboration of the different specialists and the continued use of biosecurity measures will ensure the best health care to each patient. This article is protected by copyright. All rights reserved International perspectives: Impact of the COVID-19 Pandemic on cytology A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster China coronavirus: six questions scientists are asking Accepted Article This article is protected by copyright. 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