key: cord-0841735-7wdr31yo authors: Rana, Chanchal; Kumar, Sumit; Babu, Suresh; Kushwaha, Rashmi; Singh, Uma S.; Ramakant, Pooja; Singh, Kulranjan; Mishra, Anand title: Impact of ongoing COVID‐19 pandemic on cytology: An institutional experience date: 2020-09-24 journal: Diagn Cytopathol DOI: 10.1002/dc.24620 sha: 47c1d57255bebada44e8ea499dee3c3e54d7be01 doc_id: 841735 cord_uid: 7wdr31yo BACKGROUND: The ongoing COVID‐19 pandemic has greatly impacted the health services worldwide, challenging the way modern medicine has been practiced for decades. AIM: The present study documents an institutional experience on its impact on cytology services. MATERIALS & METHODS: The cytology samples received during lock down period in India (24 March to 17 May 2020) were analysis and compared to the samples received during the same time frame in year 2019. RESULTS: The data revealed an overall 92.6% reduction in cytology samples received. All sample types were reduced with a statically significant reduction in thyroid cytology samples (P‐value: .023). There was relative increase in breast and lymph node samples; however, this relative increase was not statistically significant. The malignancy rate also significantly increased by 34.1% accompanied by decrease in neoplastic category among the samples received during COVID‐19 lockdown period. Breast samples remain the most frequent sample type both in pre‐COVID‐19 and COVID‐19 periods. Majority of fine‐needle aspiration done in these cases, during the lockdown period, were either in cases for recurrence or primary diagnosis. CONCLUSION: Prioritization of samples, proper precautions and triaging of patients before procedure helped in carrying out this procedure safely. This pandemic has led to considerable anxiety and panic not only in general public but also among healthcare professionals and has also challenged the way the modern medicine had been practiced for decades. 5 Accordingly, our practice of cytopathology has changed too. To facilitate the working of laboratories, the executive committee of the Indian Academy of Cytologists has prepared guidelines for pre-analytical, analytical and post-analytical steps in cytopathology laboratory. These guidelines will provide guidance to the laboratories across India, in the best interests and safety of the laboratory personnel. 5 Due to the potential presence of the virus in cytology specimens, nonessential fine-needle aspiration (FNA) cytology (screening and possibly benign) sampling was minimized along with prioritization of the high-risk oncological patients. Our institute played a major role in COVID-19 testing as well as patient care as it has been designated as COVID-19 Test Centre of Excellence by Indian Council of Medical Research. This study aims to share our institutional experience in cytopathological evaluation during lockdown period and to analyze the difference in cytological practices and sampling as compared to the same period in 2019. This is a retrospective descriptive study including the patient visiting to cytopathologist-run FNA clinic in Department of Pathology, King George's Medical University, for cytological evaluation during COVID-19 outbreak in India. The national lockdown period (24 March to 17 May 2020) was considered and all the cytology cases reported during this time frame were reviewed and designated as COVID-19 era samples. All the cytology cases reported during the same time interval in 2019 were also reviewed and labeled as pre-COVID-19 era samples. The demographic details were recorded from the case files and evaluated. In both the groups, pre-COVID-19 and COVID-19, the total number of samples received were recorded and were distributed in five groups depending on their site, which were breast, thyroid, lymph node, salivary glands and others (soft tissue, body fluids etc.). The final diagnosis was also categorized into five categories: inadequate, nonneoplastic, benign neoplasm, malignant neoplasm and indeterminate. The neoplastic category included cases like fibroadenoma and phyllodes, while indeterminate categories included cases diagnosed as atypia of undetermined significance/follicular lesions of undetermined significance (AUS/FLUS), suspicious of follicular neoplasm, atypical probably benign, etc. Chi-square test for proportions and Fishers' exact test were used, wherever applicable, to test for variation in proportions between pre-COVID-19 era and COVID-19 era. P-value <.05 was considered statistically significant. All analysis was done using stata 14.1. There was 92.6% reduction in cytology samples processed in COVID-19 era when compared to pre-COVID-19 era (n = 21 vs n = 230). There was female predominance in both these groups. There was significant change (P-value .02) in the age group visiting for cytopathological evaluation, so that the majority of the patients visiting in COVID-19 era were older (>40 years) as compared to pre-COVID-19 era. FNA was not performed in any patient <21 years during COVID-19 era (national lockdown time 2020). Table 1 shows the detailed demographic variables (age, gender, etc.) in both the groups. When the specimen type was considered there was a reduction in samples obtained from thyroid, salivary glands and other sites (soft tissue, fluid cytology, scrap smear, etc.). No cytology specimens from thyroid were obtained during the COVID-19 era and this reduction was significant with P-value of .023 (n = 46, 20% to n = 0, 0%). Similarly, there were no FNA done from salivary glands as well. Majority of the samples obtained during COVID-19 era were from breast (n = 14; 66.7%) and lymph nodes (n = 5; 23.8%) signifying a relative increase in their numbers (Table 2 ). Figure ries also reduced by 19.7% and 2.2%, respectively however, this decrease was not statistically significant ( Table 2 ). The main reasons for cytopathological evaluation during COVID era were for primary diagnosis of breast cancer (n = 11) followed by for evaluation of recurrence in known cases of breast cancer (n = 7) and evaluation of recurrence in known cases of phyllodes neoplasm (n = 2). Among these cases with recurrences, axillary lymph nodes were the most common site from which FNA was performed (n = 5). There were three T A B L E 1 Demographic details of patients in COVID-19 and pre-COVID-19 era cases were FNA was performed from the previous surgical scar site and one cases were pleural fluid was evaluated (refer Table 3 for details). Accordingly, our practice of cytopathology has also changed significantly. Due to the potential presence of the virus in cytology specimens, we adopted more stringent safety procedures, according to recent recommendations by Indian Academy of Cytologist. 5 Several such recommendations have been given by agencies worldwide. [6] [7] [8] [9] [10] Before performing FNA, all the patients were triaged for COVID-19 infection symptoms. None of our patients had any COVID-related symptoms or exposure history, hence FNA procedure was safely carried out. In addition, to mention none of our staff member or residents contracted the infection. Although our FNA facility is running on daily basis, few tweaks were done in our routine cytopathology protocols, keeping in mind the scarcity of resources such as protective equipment. FNA timings were limited to few set hours, which were communicated to the concerned department; so that the procedure could be carried out in one go. Attendants were not allowed to accompany patients unless necessary. The patients were called one at a time from our holding area and FNA procedure was performed quickly to reduce exposure time. Resident performing the FNA wore a protective mask with an additional surgical mask and eye shield along with double layer of gloves, the upper one discarded after each FNA. History was taken telephonically and direct verbal communication with the patient was discouraged. It was mandatory for the patient to wear a facemask and sterilize their hands before entering the procedure room. The procedure area was also properly sanitized. Once the smears were prepared air-drying was avoided to prevent aerosol or droplet generation. While microscopic analysis the reporting pathologist wore gloves and facemask. During ongoing Corona pandemic there had been a significant reduction (90.8%) in the number of sample received in our facility for cytopathological evaluation. This decrease was due to the postponement of screening activities and clinically benign cases, however, best possible services were continued for oncological patients, both for primary and recurrence diagnosis. There was a relative increase in the breast and lymph node cytology but this increase was not significant, however, there was a significant reduction in thyroid FNA (P-value .025). There was no statistically significant difference in diagnostic category proportions between pre-COVID-19 era and COVID-19 era except for malignant and neoplastic diagnostic categories. There was a significant increase in malignancy rate by 34.1% and reduction in neoplastic category by 23%. This data is probably related to the prevalence of breast samples, also the high capability to identify benign lesions by using imaging allowed to postpone nonurgent breast FNA. Vigliar et al 10 The primary purpose was the diagnosis of breast cancer or for detection of recurrence. To conclude, there had been a significant reduction in number of samples in COVID era. Breast samples remained the most frequent sample type both in pre-COVID-19 as well as COVID-19 periods. Prioritization of the samples, proper precaution and triaging of patients before procedure, can help in carrying out this procedure safely. There is no conflict of interest. DATA AVAILABILITY STATEMENT data will be provided on request The study is in accordance with the institutional ethical committee. https://orcid.org/0000-0002-1783-7689 The continuing 2019-nCoV epidemic threat of novel coronaviruses to global health -the latest 2019 novel coronavirus outbreak in Wuhan, China Coronavirus Update (Live): 4,527,811 Cases and 303,438 Deaths from COVID-19 Virus Pandemic -Worldometer Indian academy of cytologists national guidelines for cytopathology laboratories for handling suspected and positive COVID-19 (SARS-COV-2) patient samples Interim laboratory biosafety guidelines for handling and processing specimens associated with coronavirus disease World Health Organization. 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