CytoJournal- Open Access & CMAS on EUS FNA of Pancreas

Cytopathology
Open Access
Publishing in "OPEN ACCESS" Vinod B. Shidham, MD, FRCPath, FIAC
A preview of CytoJournal monograph on Professor, Medical College of Wisconsin
EUS-FNA of pancreatic lesions. vshidham@mcw.edu

Publishing in "OPEN ACCESS"
A preview of CytoJournal monograph on
EUS-FNA of pancreatic lesions
July 8, 2009

Vinod B. Shidham, MD, FRCPath, FIAC
Professor
Co-editor-in-chief & Executive editor, CytoJournal (www.cytojournal.com)
Dept of Pathology, Medical College of Wisconsin
9200 W Wisconsin Av, Milwaukee, WI

vshidham@mcw.edu

Cytopathology
Open Access

Outline
Introduction to Open Access Publishing
Impact monitoring matrices
Long term sustenance
Evolution of CMAS [CytoJournal Monographs & Atlas Series]
General
Case studies

Cytopathology
Open Access

Open-access (OA) literature is digital, online, free of charge, and free of
most copyright and licensing restrictions.

Everything published in ‘Open Access’ is freely available
online for all to read, download, copy, distribute, and use
any manner after attributing due credit to original
material.

Shorthand definition by
PLoS (Public Library of Sciences)
Free availability and unrestricted use
Peter Suber. Open Access Overview.
http://www.earlham.edu/~peters/fos/overview.htm

Cytopathology
Open Access

Budapest Open Access Initiative
“Free availability on the public internet, permitting any users to read,
download, copy, distribute, print, search, or link to the full texts of these
articles, crawl them for indexing, pass them as data to software, or use them
for any other lawful purpose, without financial, legal, or technical barriers
other than those inseparable from gaining access to the internet itself.
The only constraint on reproduction and distribution, and the only role for
copyright in this domain, should be to give authors control over the integrity of
their work and the right to be properly acknowledged and cited."

http://www.soros.org/openaccess/read.shtml

Cytopathology
Open Access

What do we mean by Open Access?
Open Access articles are:
q Universally accessible via the Internet, without
subscription barriers
q Licensed so as to allow download, redistribution and
reuse, in whole or in part, as long as attribution is
retained
q Permanently archived in an internationally recognized
repository (e.g. PubMed Central)

Cytopathology
Open Access

In brief

OA publication extends two most important components-

►Readers can freely access

► Authors do not loose copyright

Cytopathology
Open Access

OA is compatible with copyright, peer review, revenue
(even profit), print, preservation, prestige, career-
advancement, indexing, and other features.
It is supportive for the services associated with
conventional scholarly literature.

Cytopathology
Open Access

The resultant benefits are huge with service to
many groups including-
Authors, Readers, Teachers & students,
Libraries, Universities, Journals and publishers,
Funding agencies, Governments, general public
(Citizens), and so on----

Cytopathology
Open Access

We will focus on benefits
For Authors:
► Extends worldwide audience (larger than that of any subscription-
based journal, no matter how prestigious or popular)
► Verifiable http://opcit.eprints.org/oacitation-biblio.html increase in
visibility and impact of their work.
For Readers:
► Allows barrier-free access to the literature crucial for their research
(without fiduciary constrains).
► Enhanced convenience, reach, and retrieval power.
► Many other benefits related to the web-based technologies such as
full-text searching, indexing, mining, summarizing, translating,
querying, linking, recommending, alerting, "mash-ups" and other
forms of processing and analysis.

Cytopathology
Open Access

a. Traditional method of publishing due to lack of alternative Restricted
$ access, thus
Loose your limiting
copyright
TICKETS dissemination and
visibility of our
Author
Peer
reviewer
Your manuscript work
©vshidham
b. . Now alternative opportunity to publish in open access is a reality Unlimited
dissemination and
Retain your visibility
Author
copyright
resulting in
Peer
reviewer
enhanced citation
Your manuscript of our work
©vshidham

Shidham VB, Sandweiss L, Atkinson BF.
First CytoJournal Peer-Reviewer's Retreat in 2006 - Open access, peer-review, and impact factor.
Cytojournal. 2006 Mar 27;3(1):5 doi:10.1186/1742-6413-3-5
Free full text available at: http://www.cytojournal.com/content/3/1/5

Cytopathology
Open Access

To this day OA publishing in biological sciences and other areas is relatively
well established with evolution of models compatible with long term
sustainability.

Many institutions and top universalities including-

NIH/NCI
Harward
NHS (UK)
Many more

are taking steps to harvest the power of OA publishing.

Cytopathology
Open Access

------- Stuart M. Shieber, a professor of
computer science at Harvard who proposed
the new policy, said after the vote in a news
release that the decision “should be a very
powerful message to the academic
community that we want and should have
more control over how our work is used and
disseminated.”

Cytopathology
Open Access

Many publishers adopting open access
Have emerged-
PLoS (USA)
MedKnow (India)
BioMed Central (UK)

Cytopathology
Open Access

Impact matrices

Cytopathology
Open Access

Although conventionally Impact Factor (IF) has been available and
widely popular approach to measure the quality of publication- IF has
many drawbacks and does not reflect individual publication and
author(s).
IF is not available freely- and has to be dependent on info extended
by the journal or buy ‘Journal Citation Report’ from commercial
resource- Thomson Reuters
As well known best work may published in relatively less prestigious
journal but may have higher impact and vice versa.

Shidham VB, Pitman MB, DeMay RM, Atkinson BF.
CytoJournal’s move to the new platform: More on financial model to the support open-access charter in cytopathology, publication quality
indicators, and other issues
CytoJournal 2008, 5:15 (16 December 2008)
Free full text available at: http://cytojournal.com/temp/CytoJournal5115-5043123_140031.pdf

Cytopathology
Open Access

Open access journals in Cytopathology
Out of five international Cytopathology Journals
CytoJournal (projected IF for 2008- 1.06)
Acta Cytologoica (IF 2002- 0.937),
Cytopatjhology (IF 2002- 1.144),
Cancer Cytopathology (IF 2002- 1.660), and
Diagnostic Cytopathology (IF 2002- 0.991)
currently
CytoJournal www.cytojournal.com
is the only Open Access cytopathology journal.
IFs for 2002 obtained from-
http://www.genebee.msu.su/journals/if02a.html

Cytopathology
Open Access

Cytopathology
Open Access
Publishing in "OPEN ACCESS" Vinod B. Shidham, MD,As of Jan 18, 2008
FRCPath, FIAC

About SJR (SCImago Journal Rank Indicator)
http://www.scimagojr.com/aboutus.php

Cytopathology
Open Access

Comparison of SJR As of Jan 18, 2008

Comparison of SJRs for CytoJournal with other PubMed indexed cytopathology journals.
Cancer Cytopathology- was not comparable by SJR (as it is not independent Cytopathology journal, it is section of ‘Cancer’ journal without its independent
Source- http://www.scimagojr.com/compare.php?
ISSN number).
j1=CytoJournal&j2=Cytopathology&j3=Diagnostic+Cytopathology&j4=Acta+Cytologica&un=journals&inj=0

CytoJournal, Cytopathology, Acta Cytologica, Diagnostic Cytopathology
*

*
*
*
*
* * * * * *

* *
CytoJournal
was **
launched in *
August 2004.

Cytopathology
Open Access

In the pre-internet era there was no simple alternative.
However, with the advent of internet, which made ‘Open Access’
publishing a reality, has also extended numerous, real time, freely
available tools with more versatility.
These tools have been tremendously enhanced by numerous and
continuous refinements by ‘Google Scholar’
(http://scholar.google.com/).
There are many possibilities based on Google scholar and one of the
simplest is ‘Publish or Perish’ from Harzing.com

Shidham VB, Pitman MB, DeMay RM, Atkinson BF.
CytoJournal’s move to the new platform: More on financial model to the support open-access charter in cytopathology, publication quality
indicators, and other issues
CytoJournal 2008, 5:15 (16 December 2008)
Free full text available at: http://cytojournal.com/temp/CytoJournal5115-5043123_140031.pdf

Cytopathology
Open Access

http://scholar.google.com/

Cytopathology
Open Access

Free download of ‘Publish or perish’ software is available from-
http://www.harzing.com/resources.htm

Citation metrics analyzed by Publish or perish
http://www.harzing.com/pop.htm

Cytopathology
Open Access

Citation metrics analysis-
XXXXXX http://www.harzing.com/pop.htm

XXXXXX

Cytopathology
Open Access

Long term sustenance

Probono services
Philanthropy
Grants/funding
Rewards
Various financial models

Cytopathology
Open Access

CytoJournal’s business model
(Owned by Cytopathology Foundation Inc & published by MedKnow Pvt Ltd )
q CytoJournal does not charge subscriptions
q But, like all journals, it does incur costs
q Article Publication charge (APC) covers infrastructure for:
Editorial activities:
peer review activities, EB meetings, handouts, etc
Technical: Development, maintenance and hosting of online journal
system
Production: Formatting and markup of articles, indexing services
Customer service for authors/readers
q Web technology allows lower cost

Cytopathology
Open Access

Open access publication charges

q CytoJournal has continued flat APC of $1500
q CytoJournal’s APC (~$1500) are towards the
lower end

Cytopathology
Open Access

q For comparison,
traditional publishers
often charge $3000 or
more, in addition to
subscription charges
From-
The roads to open access and
BioMed Central’s business model

Matthew Cockerill
Publisher
BioMed Central

BioMed Central Colloquium
Thursday 8th February 2007, The Royal College of Physicians, London, UK

Cytopathology
Open Access

CF Member, OA Stewards, OA Stewards- Plus
Open access publishing does not necessarily mean ‘author-pays’
Waiver of Article Publication Charge
q Vast majority of CytoJournal authors do not have to pay.
q CytoJournal authors and readers could get benefits using “central fund for open
access publishing”
managed and supported by funding through Cytopathology Foundation Inc
q Individuals, Institutions, departments, societies, organization prepay nominal
charge on behalf of their authors via different schemes-
Cytopathology Foundation (CF) membership
http://www.cytojournal.com/CFMember.asp
CytoJournal (CJ) OA Stewards, CJ OA Stewards- Plus
http://www.cytojournal.com/OASteward.asp

Cytopathology
Open Access

CytoJournal promise
Special waiver to any author for
deserving manuscript based on
economic hardship with grants
from Cytopathology Foundation

Cytopathology
Open Access

http://www.cytojournal.com/eb.pdf

Cytopathology
Open Access

Open access publishing and beyond

Online study cases with
virtual slides (trainee corner),

Online CME and conferencing, Twittering, etc

Cytopathology
Open Access

(contd)

On-line line translation through Google

Cytopathology
Open Access

(contd)

CytoJournal Monograph/Atlas Series (CMAS)

Cytopathology
Open Access


Cytopathology
Open Access

http://www.cytojournal.com/monographs.asp

Cytopathology
Open Access

Monograph Editor-
Vinod B. Shidham

Contributors-
Douglas Evans
Kulwinder Dua
Martha B. Pitman
Nirag Jhala
Fan Lin

Academic editors
(Steering & finalizing Peer review)-
Martha B. Pitman
Gregg Staerkel

CMAS co-editors-in-chief:
David C. Wilbur, MD
(Harvard Medical School / Mass Gen Hosp)

R. Marshal Austin, MD, PhD
(University of Pittsburgh Medical Center)

Ruth Katz, MD
(MD Anderson Cancer Center)

Cytopathology
Open Access


Cytopathology
Open Access

Postoperative Adjuvant Therapy
Author No. Patients Med. Survival P-Valve

GITSG (1985) 21 20 .03
Surgery alone 22 11

EORTC (1999/2007) 60 16 .099/.165
Surgery alone 54 12

ESPAC-1 (2001) 146 20.1 .011
No chemo 139 15.7

RTOG (2008) Gem 187 21 .05
5-FU 201 17

CONKO (2008 ASCO) 179 23 .005
Surgery alone 175 20

ACOSOG (2008 ASCO) 89 27

Cytopathology
Open Access

Evans DB et al.
J Clin Oncol 26:3496-3502

Cytopathology
Open Access

These recent advances with pre-operative adjunct chemo-radiation for
pancreatic ductal adenocarcinoma-
definitive preoperative tissue diagnosis is pivotal.

EUS-FNA is minimally invasive, economical, sensitive, and specific
approach for retrieving diagnostic tissue material.

Cytopathology
Open Access

Raut CP et al. J GASTROINTEST SURG 2003;7:118–128.

Cytopathology
Open Access

Comparison of EUS-FNA and Final Diagnoses
EUS-FNA Result
No. of Patients
Final Malignant Inconclusive No Malignant
Diagnosis Cells Identified for Malignancy Cells Identified Total (%)

Carcinoma 197 10 9 216 (93)

Benign 0 (FP) 1 14 15 (6)

Lost to follow-
0 1 1 2 (1)
up

Total (%) 197 (85) 12 (5) 24 (10) 233

Raut et al, J Gastro Surg 2003;7:118.

Cytopathology
Open Access

Pivotal role of EUS-FNA in management of
Pancreatic lesions is increasing

Cytopathology
Open Access

Linear

Radial

Cytopathology
Open Access

Tumor
Pancreas

Needle

Duodenal
wall

Linear
transducer

Cytopathology
Open Access

GI mucosal contamination

Cytopathology
Open Access

Compare GI mucosal
contamination with low
grade and high-grade
pancreatobilliary
carcinomas (Pap stained
direct smears).
a. The cohesive sheets of
cells in honey-comb
a b configuration with bland
nuclei of relatively same
sizes in GI mucosal lining
epithelium may superficially
resemble in some areas
with well to moderately
differentiated ductal
carcinoma (b & c) and
moderate to poorly
c d differentiated carcinoma (d).

Cytopathology
Open Access

Lesion aspirate V
a. All steps performed correctly- Good sampling

V
b. Valve not close at last stage- Sample lost- partially or completely by capillary action

GI mucin Lesion aspirate V
c. Not equalized with ambient pressure- Partially diluted sampling

GI mucin Lesion aspirate GI mucin V
d. Not equalized with ambient pressure, initial stages valve not closed-

GI mucin V
e. Improper steps at multiple stages- Inadequate sample

Cytopathology
Open Access

Shidham V, Kampalath B, England J. Routine air drying of all the ------.
Acta Cytologica 2001;45:60-68.

Live cells

Cells in
smear
(surface view)

Cells in
smear
(side view)

Wet-fixed smear Air-dried smear

Cytopathology
Open Access

100X

040X

020X

002X
Gross
WF ADS
d

b

a
c

Wet fixed smear
Shidham V, Kampalath B, England J. Routine air drying of all the ------.

(Pap stained)
Acta Cytologica 2001;45:60-68.
e

WF
p

o

n

m

rehydration and post-fixed
in 95% ethanol with 5%

Air-dried smear
(Pap stained after
acetic acid)
q

ADS

Cytopathology
Open Access

EUS-FNA of solid pancreatic lesions. EUS-FNA of cystic pancreatic lesions.

Cytopathology
Open Access

Triaging pancreatic EUS-FNA aspirates.

Cytopathology
Open Access

EUS-FNA of Pancreatic lesions

Study cases

Cytopathology
Open Access

Male, 51-year
Intermittent right upper quadrant pain & decreased appetite- 4m
Pain was transient, non-debilitating, and vague, and unrelated to oral
intake or bowel movements
Also had worsening post-prandial bloating without nausea or
vomiting.
Lost 16 pounds over the past month due to food aversion.
Consumed 1-2 alcoholic drinks per day
No history of GI tract or pancreaticobiliary disease.

Intermittent episodes of transient, but severe, epigastric abdominal
pain had been experienced in the past, but he did not seek medical
attention.

Cytopathology
Open Access

CT scan

Cytopathology
Open Access

a b
Ultrasound image of the pancreatic cystic lesion.
a, EUS showed a 6.9 X 2.4 cm cyst (arrow) in the pancreatic body-tail region without septae or solid component.
b, Under higher magnification, there is subtle layering of debris (arrow) within the cyst .

Cytopathology
Open Access

Although based on international consensus guidelines (Tanaka 2006)
this lesion would have been resected,
FNA was performed using a 22-gauge Echotip needle.

International consensus guidelines for management of intraductal papillary
mucinous neoplasms and mucinous cystic neoplasms of the pancreas.
Tanaka M et al. Pancreatology 2006; 6:17-32

Cytopathology
Open Access

Only a few drops of thick, viscous, clear, mucoid fluid could
be aspirated.

CEA level could not be determined due to insufficient
specimen quantity.

The cyst did not collapse following FNA. Concern was
Mucinous cystic lesion with malignancy

Direct smears- insufficient for interpretation.
LBC preparations were also hypocellular and initially
interpreted at screening as insufficient.

Cytopathology
Open Access

EUS-FNA cytology.
(Pap stained SurePath prep).

Although hypocellular,
there were many debris

with

Detached ciliary tufts
(red arrow)

Cytopathology
Open Access

a b c
Rare nucleated cell groups were detectable. Cilia (red arrows) could be detected in some.
Note terminal bars (blue arrows) in some isolated ciliated cells.
(Papanicolaou stained SurePath preparation).

Cytopathology
Open Access

Although initially interpreted
at screening as insufficient-

Cytopathology
Open Access

Isolated intact ciliated
columnar cells with
nuclei (a through c) were
rare.
Detached ciliary tufts
(DCT) of top fragments
of ciliated columnar cells
without nuclei. (d
through o) were
relatively many.

Note terminal bars (red
arrowheads) in some.

(Papanicolaou stained
SurePath preparation).

Cytopathology
Open Access

Negative for malignancy.
Ciliated foregut cyst.

Cytopathology
Open Access

Based on symptoms of abdominal pain, food
aversion, and weight loss, the patient was referred for
surgical resection of this lesion.

The distal pancreatectomy achieved good palliation of
his symptoms.

Cytopathology
Open Access

Resection of pancreatic lesion

Cytopathology
Open Access

Ciliated foregut cyst (contd)
They may be misinterpreted as pancreatic cystic mucinous lesion and
lead to inappropriate surgical intervention, which may be avoided with
proper detection and interpretation of DCT.

A case describing retrospective EUS-FNA findings after postoperative
diagnosis of the surgical resection specimen has been reported.

However, this is the first case of pancreatic ciliated foregut cyst,
diagnosed preoperatively by EUS-FNA, to be reported in the English
literature.
Dua, Vijayapal, Kengis, Shidham.
CytoJournal (Under review)

Cytopathology
Open Access

EUS-FNA of solid pancreatic lesions

Cytopathology
Open Access

Pancreatic ductal adenocarcinoma- Mod to poorly differentiated
(Pap stain- Direct Smear-RH)

Cytopathology
Open Access

Pancreatic ductal adenocarcinoma- Mod to poorly differentiated
(Diff-Quik stain- Direct Smear)

Cytopathology
Open Access

Male, 58-year
Mass in head of pancreas.
CA 19.9- within normal limits.
No previous history of cancer.

Cytopathology
Open Access

Acinar cell carcinoma(Pap stain- Direct Smear-RH)

Cytopathology
Open Access

Acinar cell carcinoma(Diff-Quik stain- Direct Smear)

Cytopathology
Open Access

Poorly differentiated carcinoma-

DD-
Acinar cell carcinoma
Neuroendocrine carcinoma
Lymphoma
Poorly differentiated adenocarcinoma- NOS

Cytopathology
Open Access

Positive for malignancy.
Poorly differentiated adenocarcinoma-
favor Acinar cell carcinoma

Cytopathology
Open Access

Female, 71-year
Abdominal mass- head of pancreas –
duodenal wall.
NF-1
Benign neurofibroma vs other tumor

Cytopathology
Open Access

Neuroendocrine neoplasm (Papp stain- Direct Smear-RH)

Cytopathology
Open Access

Neuroendocrine neoplasm (Diff-Quik stain- Direct Smear)

Cytopathology
Open Access

Well differentiated neuro-endocrine neoplasm

Cytopathology
Open Access

Leading to
appropriate management

Cytopathology
Open Access

Peer-reviewed,
open access,
teaching material with many pictures.
Hard copy and online availability.
Opportunity for frequent updates

Cytopathology

Cytopathology
Open Access

Open Access
A preview of CytoJournal monograph on
The end
Professor, Medical College of Wisconsin

Milwaukee Art Museum
vshidham@mcw.edu

Cytopathology
Open Access

Ciliated foregut cyst
MCN
IPMN
Acinic cell carcinoma
Neuroendocrine neoplasm
Pancreatic ductal carcinoma
Metastatic endometrial adenocarcinoma
Metastatic leiomyosarcoma

Cytopathology
Open Access

Metastatic adenocarcinoma- C/W endometrial primary

Cytopathology
Open Access

Metastatic adenocarcinoma (Cell block- HE stain)

Compare with primary endometrial adenocarcinoma (HE stain)

Cytopathology
Open Access

Cytokeratin 7 ER CA 19.9 Cytokeratin 20

Metastatic adenocarcinoma- C/W endometrial primary

Cytopathology
Open Access

Pancreatic ductal adenocarcinoma- with squamoid differentiation

Cytopathology
Open Access

Pancreatic ductal adenocarcinoma- with squamoid differentiation
(surgical specimen)

Cytopathology
Open Access

(Pap stain- Direct smear)

Cytopathology
Open Access

(Diff-Quik stain- Direct smear)

Cytopathology
Open Access

Metastatic leiomyosarcoma (Cell block- HE stain)

Compare with surgical specimen
Metastatic leiomyosarcoma- Lung (HE stain)

Cytopathology
Open Access

Pancreatic ductal adenocarcinoma- Poorly differentiated with necrosis

Cytopathology
Open Access

Mucinous cystic lesion- Favor MCN

Cytopathology
Open Access

Mucinous cystic lesion- Favor IPMN

Cytopathology
Open Access

Mucinous cystic lesion- Favor IPMN with focal dysplasia

Cytopathology
Open Access

Pseudocyst (Pap stain- SurePath)

Cytopathology
Open Access

Pseudocyst (Diff-Quik stain)

CytoJournal- Open Access & CMAS on EUS FNA of Pancreas

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