Hello, it's Anthony Chadwick from the webinar welcoming you to another one of our platinum webinars. One of my favourite subjects, I love doing cytology as a dermatologist, and it's so important we can do so much, you know, in the consulting room, and we've got Bala Sladoviz coming to speak to us today. Balazs is a graduate of the Budapest Veterinary School.
He went on to be a Fulbright scholar at Missouri University and then did a residency in Kansas State University, all in clinical path. He's board certified in, in clinical path, a diplomat of the American Colleges of Veterinary pathologists. He came to the RVC in 2006, you know, I think even in, over in that time, Bala, you've seen an improvement in the amount of stuff coming into labs and things, and I know also.
Lots of residents coming through, doing Clin Path. So it's a really important area. It's great that the RBC is, is doing such a fantastic job in that area.
Obviously I'm looking forward to one of my little pet subjects being talked about tonight. So, going to pass over to you. We'll have a few polls to keep you all awake and make sure that you're nice and engaged.
But otherwise, over to you, Bala, thank you so much for doing this webinar for us. Thanks, thank you very much for the kind introduction. And it's always a pleasure for me to talk about cytology.
So, but before we get going, just to for me to get a bit of an idea of the audience, may I have just two quick polling questions. The first one would be how often do you take FNA's? So I just released that whole Ah lads, so we'll give people a few seconds to vote.
Again, they're not difficult to do, are they, and they're definitely good practise, you know, we, I used to see, you know, lumps, dogs being brought in dermatology, there's a lump. Somebody's had a feel of it, said it's a fatty lump, and that's been the, the end of the diagnosis, and it, it's not difficult to actually pull a cells out and say, yeah, it's adipocyte, it's probably, you know, a lipoma. It keeps, you know, we all, if I had a lump myself, we'd all want to know what the lump was, wouldn't we?
And I think pet owners probably feel the same about their, their dogs. So, right, OK, what we've got is 14% saying that they're doing, one every day, 43% saying they're commonly doing them, 22% saying occasionally, 22% saying rarely, and nobody says they've never done one, so we're all. You know, on the scale somewhere that we are, we are actually doing them, so that, that's just to run through that again.
45% saying commonly, 21% saying occasionally, 21% saying rarely, and then 30% doing them pretty much every day. So we've got some experts in the house as well. Excellent, brilliant.
And then just the next question is that if you take an FNA, how often would you look at it yourself versus sending it off to a reference laboratory? Right, OK, so we'll launch that one, see how we get on. I think the way to learn with this is, is often to look, you know, to take a few samples, look at them yourself and then send off and it's always a bit embarrassing because you don't always get them right, but that's probably a good way to learn, isn't it?
Exactly, yeah, that's my last slide is to tell you that basically, if you look at it, make some notes, send it away, we write, like especially my residents, we write a full page report. It's the best way to continually train yourself. So we've got a the similar sort of number 13% saying every day they look at them, so people are taking them and looking at them.
32% are saying commonly they look at them, so that's, you know, another good number, 31% has just changed. And 26% saying occasionally, and 25% saying rarely, and there is actually 8% who say. You know, they've never looked at them, which is great.
So there's, there's the experts and there's people who've got, you know, the potential to learn loads in this webinar, so everybody should be happy. Well, I mean, it is a bit, you know, difficult to, to cater for everybody, but I, I think, hopefully some, everybody will get something out of it. So, so the plan for today is that just really briefly talk why should we do this and when should we do that.
Then I briefly want to review the top tips that I gave in the previous webinar that I've done because I believe that's like the foundation to be able to do cytology and practise. And then the bulk of my talk today would be to kind of go through a systematic approach to the cytlogic exam. So it's kind of basically the principles of cytology, you know, how we talk about information versus neoplasia, how to recognise RAND cells, epithelial spindle cell tumours, and then how to tell if it's a benign.
Or malignant tumour. And of course, if we want to do something well, it's not enough to know the principles, but we kind of also be aware of the limitations. So I kind of want to go through a little bit of what is it we should not expect from cytology, and then if we have a bit of time, just talk a little bit about communicating with the pathologist.
Now, of course, you, most of you know how simple and easy and inexpensive it is to do cytology. To me, the main thing that I always emphasise that is a screening tool, and if you understand that concept, I'm pretty sure you will always find cytology helpful. Yeah, sometimes it can take you all the way to final diagnosis.
Sometimes it just helps you to rule out of things, but, you know, we don't know anything about a lesion, so we put a needle in there and then we get information. So cytology as a screening tool to me will very commonly help you in your diagnostic procedures, whether it takes you to the end or just gives you some information, but I think that's the right attitude toward cytology. Of course, the limitation is that we see is, how well you take your sample, especially the skill of the collector and how you smear it.
This is what I spent quite a bit of time in the last webinar and of course, if you look at it yourself, your experience will be a significant factor of how much you can get out of cytology, but One of the big limitation is that, of course, we only taking out cells from tissue. So, especially for tumours, or sometimes even granulomatous lesions, the tissue architecture becomes important. So histopathology is definitely a common follow-up, test.
But, you know, we all know that histopath is, is a more expensive procedure. Because it has to be sterile under anaesthesia. The turnaround time is always slower with the embedding, with the paraffin.
And actually, for RAND cells, it's like a simple mast cell tumour can be really difficult to diagnose on a histopath unless you do all the special stains. So cytology does have advantages. We see the cell details for RAM cells.
But as I said, the tissue architecture really, will only come through. Histopath and most tumour grading is designed for tissues and also immunohistochemistry, phenotyping cells is a lot more readily available for tissues than for cytology. So I think in practise, there's different ways to do it.
I think there's more than one good way to do it, whether in an ideal world you do cytology first and then histopath. I've heard people saying that, well, if it's just a small lump, they just take it out and go for histopath, you know, I don't have a problem with that, but you know, if you wanna make sure it's not a mass cell tumour, so, so I think there's certainly advantages to screen the lesions with cytology. And of course, you know, any mass or lump or bump can be aspirated if you have long enough needle and ultrasound guidance, there's practically no limit what can be sampled.
Also fluids are, are lending themselves well for, for cytlogic examination. So I think the longer I've been taught, teaching cytology and haematology is the same for me, the more strictly I emphasise the foundation and, and, and this is what my last webinars. Hopefully you guys should all have access to it.
If you haven't seen or you're interested, I would recommend to listen to that because I through in great detail of how to build this foundation. So we talked quite a lot about the the quality of the sample and the good smearing. So those, make sure that a lot of us were taught to use vacuum and suck on the cells.
We know this doesn't work. A lot of us who were sucking very hard, were also blowing really hard and trying to Spray the cells which creates terrible slides. So we know that that doesn't work.
In fact, we need to smear the slides. That's how we spread the cells and that's how we're going to achieve this nice flattened, fried egg look of the cells where you can see the detail instead of thick areas where the cells look kind of balled up where you hardly see any of the details. Now the next usual very common limitation and even in our clinic, sometimes the staining can be terrible and then they just make yourself, make your life more difficult because with bad colours, you know, it's not gonna look how it should look.
So I did share some of the key secrets to using Drew. So again, that's something you may tap into it. Then the next, pillar of the foundation is the correct microscope set up.
So I see this a lot of my online course where people send me pictures that they just have the condenser, set usually for the urine setting where you have so much contrast that you don't see the detail of the cells. It's very important to set that correctly. Also we talked about how to use the 40 X lens because it needs a cover slip a lot of people are not aware of that.
and, and then basically the last thing I talked in that, foundation talk was the microscopic skills of how you efficiently you can find the window where you want to spend your expensive time on. So, we shared some good. Top tips and of course, you know, how you judge size and things.
So, so again, I think these are the kind of things that if you get this foundation right, then it will be so much easier to look at the cytology. So I would strongly recommend to, to emphasise this. One thing that for me as somebody who's doing this for a living, I can look at a bad slide or a badly stained slide, and I will take, tell that in like 3 seconds and I don't waste my time.
But I know some of the residents in the middle of the night, for example, in the clinics would spend like half an hour on a smear, which is completely useless. But, but if you don't. Have that kind of everyday experience, it's much harder to judge why is that a slide that you shouldn't be spending your time on.
So, so if you focus on this foundation, I, I, I strongly believe that you have a better chance to start than to see the things that we kind of want to see in our cytology samples. So, so with that said, then let's talk about how do we examine a slide. So how do we approach it?
And of course, actually it's kind of it's a dull, but when you already have the slide in your hand, or even when you took it, you can see if it's really greasy or you have big clumps of cells. And then when we stay in it again, you just microscopically, you already get valuable information. And then with microscopic examination, we have to Make a distinction what we try to achieve in the low magnification versus on high magnification.
So usually we start out with a very low magnification, try to screen the whole slide that if you have a 4 x lens, it's brilliant. If you have 10, you can still scan an entire glass within like 1020 seconds maximum, and we look at the celllarity, how the cells are arranged, or they clumping or the individuals and finding, of course, the nice areas. You can look.
At a little bit of the shapes, the variability of them, and also the background can have some very valuable information. Is it really stringy or viscous or is a lot of blood in there? And if there's large organisms, this kind of low power scan can be very valuable because believe me, it's so easy to miss a big, microfilaria swimming on one part of the slide or a big fungi in one big clump and then nothing in the other areas of the slide.
So it definitely pays, dividend. Then we usually find in the right area and again how quickly you find that is going to be a major factor in your efficiency and this is where we evaluate the cells, we try to look at the inflammatory cells or tumour cells, we look at the nuclear chromatin, the shapes, the nucleoli, the cytoplasm, so all the nitty gritty of the details of the cells, and of course looking for organism needs a higher magnification as well. So, so kind of what I want to go through today is is kind of an algorithm or like a systematic approach and of course no algorithm is perfect, but, but this is what we use and this is kind of what's in our heads.
So anytime if a sample is not, of course it's straightforward, you've seen a 100 mastal tumour, you see it's a mast cell tumour. Then you don't have to worry about a complicated algorithm. But if there's anything that it's not, we don't know the answer immediately, then this would be the kind of mental processing that we, we follow and which I would recommend.
So, so of course first is always to just kind of look at the quality of the slides and And just look at, do I have enough cells to examine? Is the preservation of the cells good as opposed to being all, squashed like you can see in the top picture? Is it good spreading?
Now, a cytology smear is not gonna be like a perfect monolayer as a, as a blood smear, but you should be able to find some areas where you get that nice spreading of the cells. And, and it's a bit of a tricky question, but you as a clinician is the only person who can actually tell if what you see, does that correspond with the lesion. So of course, when we get slides sent to us, we tell what's on the glass, but that doesn't necessarily mean was that the primary lesion or could it be just some secondary lesion around the, the, the real important one.
And lastly, we can also have to ask yourself the question that depending what the sample is, do I expect normal cells? So if it's a tracheal wash, of course, we would see nice ciliated epithelial cells. You're talking about this picture on the bottom as a bad hair day, or if you have spread the prostate, you will see prosthetic epithelial cells or liver.
So we have to factor that in. On the other hand, if you aspirate a mass, like typically a skin mass and the leg, then most of the cells tend to be abnormal. Now, if we decided that we have a good preparation and we should go ahead with the examination, or if you don't think this is quite right, then and you're still at the animal, you always have the chance to repeat.
Now even if you in a really busy practise and I appreciate that you don't have, for example, time to always look at your slide, if you just can't make that distinction, you can really improve the number, you still get lots of slides from outside where there's nothing on the slide. So just, you know, having that first level of examination can already screen your slides that what you send away is hopefully will be more informative when it comes back to you. But let's say we get a great slide, and we, we have the nice area.
So then we would always try to decide, is this an inflammatory or is this a neoplastic lesion. So this is quite straightforward if you have a, a sample that's dominated by inflam. Inflammatory cells such as neutrophils, yosinophils, lymphocytes, macrophages, then it's likely to be inflammatory lesion.
If you have a dominance of some tissue cells, and of course if they're not normal, then you're gonna be looking at a neoplastic process. One thing that I really want to emphasise that if you have both tissue cells and inflammatory cells, then you really need experience. So I would kind of strongly recommend to, to get a second opinion on those because if you have information that can quite significant dysplasia in epithelial cells or an abscess will be surrounded by big fibroblasts and those the dysplastic epithelial cells or the fibroblasts can actually look quite ugly on cytology, and, and, and, and for the entre eye, they would look neoplastic.
The opposite is true if you have neoplastic process, you have the ugly cells, but then because the tumour outgrows its blood supply, it can start to have actually, necrotic areas and inflammatory cells coming in. So it's a bit like the chicken or the egg. Do I have ugly cells because it's a neoplasia and then the inflammation came second, or is it inflammation first?
So, so these kind of samples are something where I think we, we would do this for a living and do it all day long, we're in a better position to give a good estimation, but I would still say that many times we will find that even us will end up sitting more on the fence or maybe 60, 40% and recommend histopathology for those lesions. But if we decided, OK, we have a lot of inflammatory cells, then there's pretty much only one question left in our mind that we need to decide is this septic or is it non-septic. So I'll show pictures in a second, but obviously for septic lesions, what we look for bacteria or it can be other like fungal organism.
And, and one of the big hallmarks are the degenerate neutrophils. So these are the neutrophils that are actually fighting with the bacteria. And also what we look for very importantly is that the bacteria needs to be inside the neutrophil phagocytos to be significant.
If it's It's only extracellular. It could be important, but it could be just a contaminant, so we would never be able to tell that apart. Of course, for non-septic information, we don't expect the degenerate neutrophils and we shouldn't be able to see bacteria or only extracellular but not intracellular.
So this is my next polling question when we talk about degenerate neutrophils. What would you guess? How many of these cells on these pictures are neutrophils?
So less than 10%, 25%, 50%, 75%, or more than 90%. Now this is quite tricky and if you haven't seen this before, it's next impossible to say. If you've seen this before, it becomes very easy, so this is why we need to kind of discuss it quickly.
But you see 20%. Oh, how many cells in neutrophils? Or what proportion of these on the picture?
Right, I think people are falling asleep. I think people are voting there, so I'll I'll read these out to you, we've got . Less than 10%, 29% have said that.
We've got 25%, are neutrophils, 21% have said that, 50% have said 30, sorry, 30% have said 50% and 20% have said 75%, and there's 3% that have said over 90%. Excellent. So we have 3 experts in 3% of experts in the room.
As I said, this is a really tricky question, but thank you so much and, and I didn't mean to be mean, but this is like really difficult. If you haven't seen this before, it's an, it's next to impossible, but hopefully if you've seen this now, it becomes much easier. So when we see neutrophils that are fighting with the bacteria.
It's, they are kind of acting like a kamikaze. They release their oxidative burst inside them, and that's how they kill the bacteria that they phagocytos. So as you can see, for example, this cell there or this cell there, they actually, the outer membrane is fairly intact, but the cell just basically lyses from inside out.
So, actually, every single So pretty much here are severely severely degenerate neutrophils. And as you can see, quite a few of them have bacteria in them probably like if you look at this cell, you could kind of argue that you may see some remnant of the segmentation of the, the nucleus. But these nuclei will just completely swell up and become this really light pink instead of that nice dark clumpy chromatin.
And, and this is what basically pus looks like. So first you can see there's a lot of bacteria everywhere and, and this is a very important feature. So degenerate neutrophils is, is a big red flag.
We will always look for them. If I, if I see degenerate neutrophils, I will always look really, really hard for bacteria. Versus the picture on the right shows some really nice happy, healthy looking neutrophils and even in fact this one with the 3.
Bumps in it. This is a pinotic neutrophil. So this is the happy end of the life, the old age neutrophil dying, versus the one guys on the left are the ones that are dying on the battlefield.
Now, how many cells are going to be really nice and happy neutrophils versus how many will be degenerate? It's like a, it's like a battle. So if you have loads of bacteria, especially gram-negative ones, and not enough neutrophils, you will see this picture that we had the previous, slide or this one.
Versus if you're already giving antibiotics, for example, or just a very low degree of infection, and there's lots of neutrophils coming in, there could be most of them, well, well preserved neutrophils, and you may see even lots of pignotic cells, but that never rules out sepsis. So this is something that we, we have to look out for. But, but again, if, if I see degenerate neutrophils, we will always, always, always look much harder or longer for bacteria.
One thing that I wanna just give a top tip that sometime unfortunately, every stain will cause some precipitation and stain precipitate is kind of the only thing that you have to make sure that you're not calling bacteria. And so if you look at this picture, you could kind of almost see that this, this neutrophil is full of cocca in the middle. But if I focus up and down, which is again one of the key microscopic skills, the way we examine these these cells is by microfocusing on the actual cells.
So if I just focus up and down a bit, you can see that this is a big clump of staining precipitant. And what's very important is that if you look at the same precipitant, it's always a purple colour, I the same colour as the nuclei. It can be lighter, can be darker, tend to be a bit variable in shape and sizes, versus bacteria will have a very unique colours.
So if you in the next time in your practise, you see a nice septic inflammation, an abscess or something, try to get a good look with your own stain with your own micro. Scope, what's the colour of the bacteria? It will vary, 90+% of the bacteria will be that exact same colour, which tends to be like a dark, very dark blue, dark, almost green, versus the same would be a dark purple.
It's a, it's a subtle difference, but it's a definite colour difference between them. And, and bacteria should be quite uniform, at least the same type of bacteria with a nice outer wall of them. Excuse me, that we should be able to see.
So, so, so again, that's kind of what we look for with, with inflammatory lesions. Sometimes it's not so much the neutrophils, but macrophages dominate and if you ever come across these non-staining, rods in macrophages, that's pathogonomic for micro. Bacterial infection or sometimes we see, some nice, branching, fungal hyphae, and that tends to be the neutrophils and macrophages, or, we may see like foreign body reactions, again, lots of neutrophils and macrophages.
So that's kind of pretty much it for an inflammatory lesion. If, on the other hand, if we think that that 1st, 2nd level when we looked at is this inflammatory, with this neoplastic, if we think that it's mostly tissue cells, then the next question is going to be, is it a round cell? Is it an epithelial, or is it a seymo or a spindle cell tumour?
Now, if you look at this nomenclature, it's a bit funny that it's not very. Scientific that one talks about the shape of the cell. The next one talks about the origin.
The third one is you can use either way, but it's actually practic, it's quite practical and it works well, in the everyday practise. So, so basically then the next question is that how do we, decide which category it is based on what we see in the microscope. So for RA cells, probably the most important aspect will be that when we screen the slide and we look for a nice thin area, that the cells should be individual.
So instead of forming clusters of clumps, generally these cells are not massive, so if you compare them, you always use neutrophils or red blood cells as a comparison. So they're kind of small, medium size, obviously, as the name implies, it's a round cell so the nice outline is round, usually have very good well defined borders and the nuclei tend to be round as well. And also what's very important that we should get lots of cells.
So if you look at a cytologic sample and you think it's neoplastic and you think, oh, I think this could be a round cell tumour, but I wish I had a few more cells to look at, then you have to go back and reaspirate because you should have lots of cells when it's a round cell tumour if it was a good successful sampling. Now, as I mentioned though, you have to be a bit careful because if you, if you imagine a whole bunch of tennis ball and a tennis court, if you get them all together, they could start looking like a cluster, so in the middle of this picture, and sometimes they even start to mimic like this cell to cell junctions. But as soon as you go out to areas where the cells, where the preparation is thinner, and if you kind of untrained, you could use the red cells.
Can you appreciate that on this right images? To the cells are piling on top of each other or up down here as well, versus if I go to an area like here on the left picture on the top corner or in the bottom where the red cells become individual, then of course the, the sample will be thinner there. So we need to judge this individuality or clustering in the kind of well, spread areas and not in the, the really chunky areas of the slide.
Now, the good thing is with round cell tumours, you probably a lot of you are familiar with this, that it's a very finite list, so we can have lymphoma, which we saw on this picture, it's very classic picture. The histiocytoma that we could see in this picture is really bland looking cells with the blue cytoplasm and you see this fading away of the cytoplasm towards the rim of the cell. That's a very characteristic, picture.
The mast cell tumours, which is the picture on the top with the nice purple granules, you can see. Some eosinophils commonly in there as well and some big plump spinal cells. Plasma cytoma in the skin, very classic plasma cells, with the eccentric nucleus, abundant blue cytoplasm.
If you can contrast that to the lymphoma, they usually have very small amount of cytoplasm, for the, for the cells versus here we have quite a few, quite a bit, and, and as you can see, most of these cells have the nice gorges on this lighter staining area right next to the nucleus. If you guys deal with animals coming from the Caribbean or from exotic areas, you might come across transmissible venereal tumour which belongs to this category. And, and this creed or melanoma is sometimes listed in here because if we see the melanin granules, we know what cell it is, but it doesn't necessarily always behave as a ran, can look like a round cell tumour, but can look like, actually as a spindle cell or as an epithelial cell tumour as well.
Now, On the other hand, if we think that, so if I start to see the cells that are in kind of bigger clusters, or even in the really thin areas, at least, at least 4567 cells, but they want to stay together, then we usually think along the lines of more the epithelial cells. And these are much larger cells. So if on this picture you see this big cluster, there's a neutrophil down here or look at the red blood cells.
These cells are much larger than the ones we looked at. On the previous picture and one of the other hallmark is the cell to cell to cell junction. So if you focus, microfocus up and down the cells, these really bright lines will come in and out of focus, which is the demosomes where the cells are joined together, but you have to focus up and down to appreciate these cell junctions.
The cells tend to be kind of oval, can be angular, and they still tend to have a fairly round, maybe oval nucleus, typically central, bit part central, and, and definitely more cytoplasm than what we saw, for example, with the lymphoma or even with the histiocytoma. And again, we should have a good cell yield. So, we should be able to get a good number of cells, out of these, lesions.
to examine. And, and then the last category is going to be your spindle cells. So, as the name implies, the hallmark of this type of tumours is this fusiform to state, to plump appearance where the cells will have, cytoplasmic tails in 12, or multiple directions, and usually, Actually, I forgot to say epithelial cells should also have really nice well-defined cell borders versus these spindle cells are a lot more difficult, as you can see they kind of, you can follow the cytoplasm for a while, but then it just kind of, well, where did it exactly end?
So it blends into or is this already the next cell. So, so the cell borders are, are, are less defined with spindle cell and neoplasia. The nuclei tend to can be very elongated, like almost like cigar shape.
The uglier, the more malignant it is, the more rounded or oval it tends to be. And overall, the cells should be actually more individualised, if you look in the thinner areas, but as you can see on the bottom of this picture, you can sometimes have big chunks of the, the, the tissue, so that will be a big clump. But when you go to the thinner areas, the cells are individual, but, but they kind of may blend into each other with their tails, just that's how they look.
Now spindle cell is the one lesion where it's the weakest aspect of cytology, and this is where you, like for especially a benign, like a fibroma will be very difficult to get cells out of it. So, versus, in fact, it's the more cells you see with spinle cells, that's almost part of the, the criteria of malignancies that we're gonna talk a little bit later today, because a, a real, this is connective tissue. So, so a healthy or like a fibroma, the cells will really hold on to each other, very difficult to get them out.
So this is probably where you may not see a good sample. This is probably the only one where somebody could potentially try to use aspiration, like with a syringe to use vacuum, but because the cells are not coming, you will still mostly just get blood and then it's not gonna be helpful anyway. Another interesting feature that is common with mesenchymal tumours is the matrix production.
So in this picture, you can see these nice purple fibrar material woven between the cells. That doesn't make it malignant or benign, but that's a typical feature of spindle cells because they lay down either collagen or osteoid or chondroid depending on what the cell types are. So, now, with that said, these three categories is what we always try to do, but actually the most, the two most common lesions would not fit into these, any of these categories.
So, so I'm just gonna go through this just really briefly and if you've done cytology. Ever, then I'm almost certain that you already exactly know what I'm showing here. This looks like a big clump of chicken wires.
These are massively large adipocytes. So these are huge fat cells. So this would be one big fat cell, and they usually have a small nucleus somewhere hidden.
So a big conglomerate of, of, of adipo or, or adipocyte like fat cells is very typical of lipoma or, but, so technically a lipoma should be a mesenchymal cell tumour, but these cells, the, the fat cells are actually not spindly at all. On the other hand though, for the untrained eye, it can be a bit misleading that if you look around, there's a lot of elongated nuclei in here, but if you actually follow them, there are long channels, and believe it or not, these are actually blood vessels. So these are the endothelial cells and if you look close enough, you can actually see the red cells marching up here and then there's even a neutrophil there.
So I can promise you if the neutrophil is chasing the red cells, or the red cells are chasing the neutrophils, but, but this is, this chicken viary. Appearance commonly comes from all the capillaries, and it's important not to think that these are actually spindle cells, and, and thus a spindle cell tumour restar, but this is a classic lipoma. You're probably all aware of that when you aspirate it, the sample looks very fat, and then the alcohol of the fixative will dissolve it.
So it's quite important to When you make the smear, if you had too much material, I showed a trick again in the previous webinar to allocate it into more than one slide, because if you just float the spreader slide on top of the fat, then the cells may not really adhere to the glass, but if you kind of, if you control the amount of material there and you kind of do press down a bit. With the glass, you don't have to, a lot of people worry about that, the alcohol will dissolve the cells. The alcohol will dissolve the fat, which we see sometimes at the end of the slide where it hasn't been stained, you see these fat droplets, but you should still be able to get the cells, and you're probably all aware of that.
There's nothing. Ideologically different about aspirating subcutaneous fat versus lipoma. So many times you get lymph node aspirates or attempted lymph node aspirate, and all we see is these big chicken wiry clumps of fat cells.
It looks identical to lipoma. So it's a question of how certain are you that those cells came from the mass. And my other exception to my nice algorithmic rule would be the typical dermal mass that you see lots of, and lots of old dogs.
You can see multiple of them, but I actually don't really see any cells, but you see these lots of, blue, angular structures which are basically squams. So this is the, stratified squamous epithelium that produces the Slams, but this is actually now in a cyst and you see these large angular light blue, structure that fold up and that's when it becomes so dark because it's so thin that they tend to fold up and it's also not uncommon to see cholesterol crystals from the cells breaking down. So this is the classic follicular epidermal inclusion test where this Epithelium, the stratified epithelium instead of producing the squams to the top, which is shed from our skin, it actually becomes a cyst and they keep producing the squams, so then that cyst getting really impacted with the squamous, this blue material that you see on the slide.
It's almost you can diagnose this with without a microscope because when you aspirate this, those of you are old enough in the audience who you Blackboard with the white chalk. This is, it's going to really dry like a bright white chalk on the glass before you stain it. And then when you stain it, you see all these abundant blue squeamous debris and squamous material.
Cutting it out is cures it, but it's extremely irritative and it will eventually rupture and then it just creates a really ugly inflammatory lesion that doesn't really want to go away. Also, benign hair follicle tumours can have similar cysts next to them, so we always look around to see, do I have inflammatory cells, so in other words, is it ruptured or do I see some basal cell clusters that would then make it into a hair follicle tumour. So, so again, these are one basically some of the most common lesions which don't follow my algorithms, so I kind of wanted to, to go through these very quickly, but for most other typical lesions, I would recommend to kind of follow this systematic approach.
So we only really have one question left, and with neoplastic lesions is, is it benign or is it malignant? So, an epithelial tumour, of course, would be benign would be an an adenoma versus a carcinoma, mesenchymal is a fibroal fibrosarcoma, and it actually runs out tumours, it's a bit of an exception to this because generally the entity itself is what's important. So, we, for example, know that a histiocytoma is, is, is a benign lesion that in fact can go away on its own and cutaneous plasma cytoma is a benign lesion.
Probably mastal tumour would be the exception where the cells can look really bad and then it's more likely a high grade. Or they can look very uniform and then it's a low grade, and lymphoma again is lymphoma we start now, learn more and more about them, but, but still, we judge those tumours more based on the entity than the cytologic pictures. But for an epithelial or a mesenchymal tumour, we definitely, will examine the slide closely and we're gonna look for criteria of malignancy, like cytlogic criteria of malignancy.
The underlying principle of tumour cytology is that we unfortunately don't see the actual tissue, but we take out cells from that tissue. Now, if you think back when you were in vet school year one and you were looking at histology, if you think of a normal tissue, that normal tissue will look like very nice and uniform cells, nicely spread out evenly, so it probably looks something like a honeycomb, versus if you think of a malignant growth of a tissue, it's gonna be the exact opposite. Every cell will pile on.
Top of each other, one will be small, one will be big. There will be very abnormal features that we don't expect from a nice organised tissue proliferation. So, so basically the principle of tumour cytology is that we take cells out of a lesion and we look at how variable the cells to each other.
The more variable they are, the more we I think that this is likely coming from a malignant growth of tissue versus the more uniform the cells, the more likely that it's a benign lesion or potentially a hyperplastic lesion. Only exception to this is going to be lymphoma because that's a clonal proliferation. So every single cell is the daughter of one cell, so the cells should be very, very uniform.
But for carcinomas, sarcomas, we will definitely look for this pleomorphism. We have cell cri criteria, nuclear criteria, cytoplasmic, generally, nuclear criteria are the strong ones, and we want to see at least 3 or more of those. Unfortunately, there's no, black line of left of everything is benign and right of everything is malignant.
There's a big grey zone in between these plastic lesions, hyperplastic lesions. So the more criteria we see, the more likely it is malignant. If you only see a few criteria then we Have to be kind of careful not to overinterpret the lesion.
So just to give you a couple of nice ideas with pictures, cellular level criteria would be anisocytosis, so you can see the variability of these cells, and then macrocytosis, this massive cell on the top, cell crowding, this is not a nice uniform organised cluster cell cannibalism on the bottom where one tumour cell is eating another one again, that's not something that a normal tissue should be doing. Nuclear criteria, so the same way we have variable cells, we can have variable size of nuclei, we can have multinucleation where for example this cell has at least 12345 nuclei, and if you have more than one nuclei, odd numbers are always worse, like 3 or 5 versus 2 or 4. Some tissue cells, even when they're normal, can be binucleate or even have 4 nuclei.
Macrokosis, like very large, like if you look at this whopper compared to the others, that's quite a strong criteria. Also a high nuclear to cytoplasmic ratio. Now, if you think of a small lymphocyte that has a very small amount of cytoplasm, so, or basal cells, those would be a high ratio, but that doesn't matter much.
What we worry about is in large cells. If you have a big nucleus, you want to have a lot of cytoplasm around it instead of just a small rim of cytoplasm. Now, increased mitotic figures.
Remember, mitosis itself is not a bad thing. We want cells to divide, but too frequent. So in this picture, there's 123 just in this small area.
It is, it can be, a criteria of malignancy and abnormal figures are, are very strong criteria. So if you look on this picture, that's really nice cartwheel is what you expect. And if you magically turn this 90 degree, then that's when you see more like a lineup of the chromosomes.
So this kind of goes around in a loop, that ring that we can see on the bottom. But when that loop is not intact, and in fact here it looks like a T bar shape, and then we have even lagging chromosomes or here there's very uneven distribution of the chromosome, that's a strong criteria of malignancy. When we look at the nuclei, the chromatin pattern is, it can be quite telling, but arguably this is the one that probably needs the most experience.
So like you have to see a few cells before you can start to appreciate the really abnormal course chromatin patterns. And nuclear moulding, for example, these cells are kind of butting into each other. That's another strong criteria.
And then within the nucleus, nucleoli, so very large nucleoli that's for example, bigger than a red blood cell is a very strong criteria or when you have very abnormal shapes, so this one is kind of angular, that's a strong criteria, or this one had actually different size of large nucleoli, again, this is not something a normal tissue should be doing. So basically, that's kind of what I wanted to show you as the principles of how we look at cytology and with how we go through this algorithm. So in the next few minutes, what I want to also talk a little bit about is the limitation.
So, where to, to be careful what not to expect. And spindle cells are arguably the weakest aspect of cytology. Cytology is absolutely brilliant for round cell tumours, in fact, can be better than histopath.
It's great for carcinomas, but spindle cells are a little bit difficult. The granulation tissue can have really big plump, ugly looking spindle cells versus a well differentiated sarcoma can actually look fairly uniform. So you have to be careful.
That, interpreting these does take experience. And even us with experience, you will very commonly find in our report that, you know, you need to take a histopath. And I know sometimes people get a bit frustrated and thinking that, oh, why did I bother with cytology?
I should have just taken a biopsy. But remember, I said in the very first slide, it's a screening tool. So this dog came in with a big mass in the leg.
We don't know anything about it. So, if, All of a sudden now we took a needle and we saw big spindle cells. Well, we already kind of think it's not a mast cell tumour, it's not a lipoma, but we have cells that we can't fully account for.
So I think in that context, it didn't really help us to reach a diagnosis, but still cytology helps us to rule things out, and it also helps us to, to kind of justify potentially the more expensive procedure. So I still think cytology is valuable in those cases. Now memory tumours would really lend themselves well because it's super easy to aspirate them, but unfortunately, the biologic behaviour of memory tumours is dependent on stromal invasion and evidence of metastasis.
Both of these are histopathologic terms, so you really need to have histopath to do, to decide if it's a benign or malignant neoplasia. But on the other hand, if you have a ventral abdominal mass that can be within. Like right under a nipple.
Aspirate can be extremely useful. I've seen one before. I was convinced that it's a, spin, it's a memory tumour, and after I poke a needle in there, it was wall to wall mast cells.
So differentiating those tumours from a memory tumour, cytology is great, but after we see these nice clusters of epithelial cells that can be epithelial and spindle cells together, then we usually stop and we recommend a histopath for deciding if it's benign or malignant. Now, as I mentioned, most tumours, the more malignant they are, the uglier the more variable the cells are, but there's a couple of tumours that haven't read the book. So a thyroid carcium in a dog is pretty much malignant until proven otherwise, because more than 95% of them are malignant, and they actually can be.
A very uniform population of cells, so they may not have much of these criteria that I described. In glandecrine adenocarcinoma, those blood tumours is a similar, aspect. They they can be fairly uniform cells even though it's a very aggressive tumour.
Now, I already mentioned this that when you have inflammatory cells and you have either epithelials or spinle cells together, as I mentioned, you need to be quite careful and either seek a second opinion or if that becomes a bit unfeasible, then I would just go ahead and do a biopsy because that will be more informative than, than cytology even with an expert in those kind of cases. Now, one thing that's very important that, and I kind of alluded to this earlier that, when I look at a slide, only I can only diagnose what's on the glass, but whether it's that the lesion or not. So these pictures were from a cat, which had a really ugly cauliflower-like growth on the ventral aspect of the tongue.
That just looked malignant no matter what. But actually we could palpate the mass between the mandibles, and the cat was so nice that we could just poke a needle in there without any sedation or anything. And we got this really nice picture on the top, which is lots of neutrophils.
You can see intracellular bacteria. So it's a perfect cytologic diagnosis, septic neutrophilic aidate, but that's not the. Clinical diagnosis, this cat clearly had a big tumour growing on the tongue, so we had to anaesthetize the cat, chop off a small bit, bit of that tumour, and lo and behold, it was a squamous cell carcinoma.
And you can see on this bottom, there's the big ugly tissue tumour cells, but there's a lot of neutrophils and inflammatory cells in there still. So again, those are more need more experience. Now, with bacteria, it's always a question of how long I look for.
Sometimes I would look for the slides for 10 minutes and then the last minute I find the bacteria. Now if I stopped at 9 minutes, I wouldn't have found it. So we never rule out sepsis from cytology.
We just look very hard if we see those degenerate neutrophils. But you always recommend to do cultures as well. This is especially true if the animal is on antibiotics that will really kill a lot of the bacteria so then become very difficult to find them and joints are notorious to find bacteria so you probably all know how hard it is to prove from a joint that you have to take the little membrane and culture that.
And, kind of lastly, this is probably the least favourite slide of mine and but I want to mention this briefly that some tumours are so aggressive, such as transitional cell carcinomas, that they can actually see it. So it has been documented that poking a needle through the abdominal wall into a bladder mass, for example, you can see the tumour cells as you come out with the. Needle.
I have seen some of these, animals being operated and they came back with the entire abdominal wall where the suture line was that every needle as it went in and out, there were, transitional cell carcinoma. So, in these cases, people now tend to be very, cautious and use more traumatic catheterization to get the cells from the inside, so we not see. In them, I think you can a bit argue that it's a, it's a fairly aggressive tumour, so the survival is not great, so getting a good diagnosis is probably very valuable, but of course the veterinarians, we don't want to hurt anymore and cause even more trouble.
So this is something, now, is this a common problem? I would say absolutely not. We may not.
We may not live to see the results of this because these animals usually end up being euthanized or, or, or, or because of their problems. So, but in the real everyday life, you don't see this as a big problem, but this is something just to be in the really back of the mind. But I would not stop doing cytology because of this because it's, it's a very small problem and if you have this problem, it's an aggressive tumour like minor lesions are not gonna see themselves.
So that's kind of what I wanted to talk about in terms of building that foundation, so you get the best chance to read the slides out well and then following this kind of algorithmic approach to, to make those distinctions and even if you just go to level 1 or level 2 clinically, that will give you very valuable information so you don't have to necessarily be able to go all the way down that list. And, and then I wanted to kind of share with you some of The limitations of cytology or the things what not to expect or where not to be over, not very not to overcall things. So for the last few minutes, just wanted to get a couple of aspects of if you look at the slides and then you send it off to a lab, we usually don't mind staying slides, especially if your dri is maintained well.
So if you follow those tips that I, I shared the last time, We absolutely have oil on the slide, you can have dirt on it. We can wash it off. We don't mind it.
On the other hand, we do like to get unstained smears because we can use our own nice white stain, and we love those colours. So we had all possible send us unstained smears as well. But if you only have one that you stain, it's fine with us.
The little tip is that pen will, wash off with the alcohol, but pencil stays on the glass, so it's the better way to mark them. And, and I usually, if you send it into a lab, we really like to get a proper signal man and a good history. Now, writing a history is an absolute art and sometimes you get a 7, 10 page printout of the entire document from the computer when it was vaccinated, when it was a puppy.
And of course we look at a lot of slides a day, so we don't have time to go through. 7 pages of unrelevant information or irrelevant irrelevant information. So, so writing a concise but but targeted history really helps us.
And one funny thing is that when you look at a lesion in front of you, it tends to be so obvious what it is, but you kind of have to describe it to somebody who is not seeing the lesion. So, but it's The favourite example when people say abdominal mass. So yeah, if you're standing in front of a radiograph and there's a massive abdominal mass, that's one thing, but equally like a tumour on the skin of the abdomen can be described also as an abdominal mass or I had this one said the radial mass, but yeah, is it in the radius, the bone, or is it just in the in the skin.
Now, talking about the skin. This is one very important distinction. Is the lesion dermal, ie moves with the skin, or is it subcutaneous, so the skin moves above it.
80% of the submission would not tell this to us, but let's say if you have small uniform epithelial cells in the ventral neck of a dog, if it's a dermal mass, it's probably nothing, it's a basal cell tumour, a tri. Blastoma. If it's a subcutaneous, it will kill the dog because it's a thyroid carcinoma.
So, you know, knowing if it's dermal subcutaneous is very important. And then, of course, how the tissue was growing and, and, and the previous history or lesions helpful. Also, as I mentioned, knowing if we have antibiotics on board helps us with the interpretation.
Just a couple of tips in terms of sending off slides. Any formalin fumes will completely destroy haematology or cytology slides. So you have to make sure that there's no formalin jar open if you're doing biopsies at the same time, you're making imprints, and you have to, if you send it to the lab together, you have to double.
Triple bag them separately, so there's no even the closed formalin jar can't give up enough fumes to destroy the slides, and it's very important not to put glass slides into the fridge. Those of you with the glasses know what happens when cold glass goes into the warm air, so water condense on it, and that will destroy basically the sound. So just lastly, this is a kind of a, a constant struggle for us that people feel many times that we need to be blinded so they don't give us any kind of history.
Somebody who's a trained board certified clinical pathologist, and I have to say, in 2006 when I started in the UK there were very, very few of us. Now, I would say 80, 90%. The people who read slides for money will be actually trained in clinical pathology or in cytology, so you have a much better chance now to get really good information from clinical pathologists.
We have been trained for, you know, years to, to only report what's on the slides. So we're not going to get biassed by what you tell us, but it certainly helps a lot. Look for specific things or when I report, I will report what's on the glass, but my comment will reflect on your history and on the things you told me and I can tell you that whether it fits with it or it rules it out or is it inconsistent with that.
So I feel that I can give you better information if you give me better clinical history. So in summary, cytology is a pattern recognition. So if you practise it and you have gain experience, you will get better at it as simple as that.
If you follow those microscopic techniques that I shared in the previous webinar, it will make you certainly more efficient and I'll. Show you the great resources in the next slide that you really want to have this nice textbook next to the microscope. They have excellent resources now and even us, we would look at those books for, for pictures from time to time of my residents do it all day long.
So it's very useful to do them. I think the main thing to emphasise that if you do cytology in-house, lipomas, mast cell tumours, follicularsis, these are very easy to recognise, and it's, it's really a waste in my view not to do that in-house if you have the time. Of course, if you're in a really busy practise where you see a client every 5 minutes, then that may not be feasible.
But if you're in a PDSA clinic where you can only do what you can do and not sense the fan, it's a really valuable thing to be able to do it. And, and what we kind of mentioned in the very beginning, I think what's brilliant is that if you take a sample and have the time and have a quick look, maybe even make some notes, and then you send it away to a lab, we will write you a nice long report and, and I mean technically the owners should pay for it because you they're getting service, so you get a free education and you can continually train yourself if you have the interest to look at slides. Just to kind of finish off, this is a really cool paper where they looked at what were the most typical kind of.
Diagnosis that they achieved. If you look at from about 220 lumps, lipomas, mast cell tumour, and epidermal inclusion cysts were about almost 80% of the lumps and bumps. So, and if you can actually add lymphoma and a histiocytoma to it, you could base, these five categories needs about a few days of training.
So with few days of training, you can diagnose 90, close to 90% of the lumps and bumps in practise. The bottom of the list. The list, the other 10%, that takes the years of experience.
But, but again, I think it's, it's a really useful technique in practise that it's worse to put the extra effort in to, to get trained a little bit to recognise those, those lesions. And as I promised, these are the really nice textbook, even if you get on eBay, a previous edition of them, they're still brilliant. So I would strongly recommend if you're interested in doing cytology to have one of these next to you with the microscope.
So with that said, I would be very happy to entertain any question and again we have a bit of a mixed audience, so some of you more experienced, some of you less experienced, so, if you're very experienced, I apologise because this was more to be, you know, the principles of cytology, but hopefully you still get something valuable out of it. And again, I would be very happy to answer any questions. Thanks, sir, thanks, fellas, .
Stu and I were were fighting over the new button, so I think he was trying to help and we got there in the end, which is the. It's always good that the photographs are always good if nothing else, because, you know, we learn so much by, you know, looking at the photographs, don't we, so that was. Exactly.
It was a big help. . Hopefully I'm sounding OK.
I know what one person was saying I was breaking up a bit, just to let you know, I'm down in London, I've been doing a, a few bits and pieces down here. I, I very, I, I got some time off to, to go to the, London Wetlands Centre today, so if you haven't been there, do go and have a look. It's, it's really interesting watching the shovelers and the pintails and everything there all, playing away in the, in the, in the pool, .
So if I am breaking up though let me know and we can obviously look at that. Jill's just saying can we have the textbook page up again do you want to just whiz back a couple of slides . Angela is saying, what was the first talk called so I can find it in the archive.
I think it was the top tips, hold on, I can give it to you very quickly, Angela, if you want to go and have a look at that on the website, so you should be able to find it. We do need, and I know this is a failure of mine, we do need to do some, Little webinars on the website just so that you can get familiar with the new one, but obviously do use this time to come back with some feedback on on website which I think it was called the tips and tricks for getting the most from cytology in practise. Yeah, and I think Stu might have a look at it as well, cause I suspect it's in Clin path.
So, Perhaps two of you have a little look for that, and if we can find it, we could even share your screen so people can see it, because I know I, I think I was at it, I remember that I certainly looked at it afterwards, you know, really useful, and these are. You know, things that are. You know, very open for people, you know, you've got to have a nice microscope, I think if you're gonna start looking at the smaller cells and want to see bacteria and the like, you know, you need a good.
40 or or possibly even 100 to see the bacteria, so certainly with all the cytology for dermatology, you know, I like to go down to oil to the malashesia and the staph and stuff. Sue's got a good question. I have a picture of cells in fresh urine from catheterization of a suspected bladder tumour.
If I email to you, can you give an opinion? Lab sitter was negative in urine, so you'd sent that in urine, but it wasn't in a catheterization or you just got lucky seeing some cells, do you think, Sue? Let's see if she comes back with that, but yeah, yeah, yeah, yeah, I would be happy.
I have my email in the, the, the procedure or the, the notes that I gave. So if she if she sends me the picture, I'm happy to look at it. One thing that is very important with urine samples, but I strongly always recommend is to try to make fresh preparations because cells don't like to sit in urine.
Uine is not really a, a, a nice environment, so when you send. It off to a lab, those cells tend to deteriorate, especially tumour cells. They're quite fragile.
So it's invaluable with, with, with that kind of traumatic bladder catheterization or any kind of cells you get out of the, urine to kind of spin some of it down and make, make a smear of that sediment gently and, and then just air dry it and send it along with your, your urine sample because we, we see a lot of deterioration of the cells and that makes them usually a bit more difficult to interpret. But yeah, if, if I get them in email, I'll I'll try to give you my opinion. And even, you know, obviously leaving urine for a time, think sediment out, don't they, so you get all of the the crystals forming in, in the urine as well, so you can get ways, can't you?
Yeah, no. Jill is saying, treatment best if ever read a small amount of quick which can be changed, from last lecture. So come on, can you, can you repeat that question on that a bit.
And treatment best tip ever read a small amount of diff quick, which can be changed read from last lecture. So were you saying just topping up diff quick and not throwing it all away, or? No, I think it was because I, I, I shared this picture where you can use like a slide boxes.
You put in a Styrofoam. And then if you don't use a lot, if you don't Look at a lot of slides, then instead of having big copper jars full of stain and chucking it every two weeks, just using small volumes in those slide boxes, then, then you can actually just chuck the whole box away and then you have to go clean it because that's another very common problem and people don't clean the jar and they replace the stain, and then they just ruin the stain immediately with the rod on the side of the glass. I, I think that's probably what she's referring to.
Because one of the, the, the vets was saying, you know, does old stay create sediment and precipitate and you get, you know, it can really be quite confusing on slides, can't it? Yeah, but it's the colours, so the colours will really change. So like that's why everybody has green red cells when you look at different pictures.
So, so the, the colours will change and there was another important tip that I shared that when the blue jar has this mirrorry film on the. Couple of it. The worst thing that can happen that people like shoved it into the, the stain with the glass instead of, you need to take a, a bit of a paper towel and just blot it off and suck up some stain, and rather lose that stain than than actually, because all that film will then break up into small little bits and that will all end up with the slide.
So, I mean, unfortunately, even freshting will cause precipitation. There's no way around it, but, but it's really the colours that will completely change and then the, the degree of staining or the detail of the cells and like the platelet, granules will not stain at all or even polychromatophils and a blood smear, you cannot see them and the stain is all there, everything is just green. But, but it's a gradual change, so people get used to that colour and then they don't appreciate that how off the colours are when the stain is not fresh.
You're obviously using a lot of stain, and I know we probably mentioned this. I mean, I certainly with dermatology would have wanted to be changing it every, you know, few weeks, and presumably you're changing it more regularly than that because you're going through so much obviously. We, we have used the right stain, so we have an automated stainer that's it's a bit better stain to, to use, especially for haematology and we love it more for cytology, but, but definitely if it's maintained well, it's, it's.
It's pretty decent, but, but that's a good point that you mentioned with erm, for example, I would always recommend to have two separate sets of stains for blood smears, cytology one, and then the dirty stuff for the other one. That's where the small boxes come in handy because then instead of having two sets of coupling jars full of stain and trucked every 2 weeks, you'll go through the bottle very quickly versus with the small volume, you, you can then actually, use less stain or not go through the bottle as rapidly. Susan actually said, it was sent in urine, which was obviously wrong to the lab.
She did a fresh smear in-house, so, just proves your point. Mhm. Yeah, the fresh may will always be better, yeah.
Just while people are maybe thinking of a couple of more questions, just wanted to give you a bit of news about bits and pieces. We're obviously in the middle of the mood series and I've been getting some really nice feedback from that. So, obviously just to, encourage people and give people tips from Mike, Mike Scanlon, how to, you know, maintain a positive attitude, .
It's National Sleep Day on Friday, so, . If you struggle with sleep, the things coming out on, on Facebook, we've obviously done the sleep course, which I know, it was interesting, Balash, we had, we've had several, 1000 people go through the mindfulness training and then, you know, smaller numbers obviously going through the sleep training. Obviously most of us, thank goodness can sleep well, but.
You know, if you can't, it's really debilitating, and I've been reading quite a few articles on it. You know, if, one of the things is you need this 16 hours a day, if we don't get 16 hours a day, the brain starts to shut off. And if we do it for a few days and we're driving tired, it's almost like we're also, you know, we've had a few drinks.
Mhm. So it, it is such an important issue because I think if you do suffer with insomnia, it really becomes quite debilitating, doesn't it? Not that I have, yeah, unfortunately, yeah, I don't, I have little kids, so for me sleeping I can sleep in any, any position.
But, but I know, and, and I'm not trying to make a joke. It's, I, I fully agree with it. That's an extremely important for the brain too, yeah.
I'm, I'm just waiting to give it a couple of more seconds. Ask which of you and you can perhaps just put yes in if you are. You know, interested in using or you do use LinkedIn, because we're one thinking about do we need to do something, I think we did one maybe a while ago, but is this something that you look at, I think it's a good area to potentially find, you know, people for.
Jobs, but it's also nice, . You know, we use it to find speakers and so on. One of, you know, if you'd consider.
Putting a not an endorsement but a recommendation down for me, just with the you know, obviously if you. With the work that we do with webinar vets reviews are really powerful if you never have. To do a, a Google review me on Google, I think we've got one review, which is from Katrina in In in Scotland that I'm very grateful for, but it would be lovely to have a few more reviews on, if you think we give a good service.
If you think we give a bad service, then I don't want you to talk about it at all. Joke. I'm sure that most of you are on, wouldn't be on if you, if you thought we were a load of rubbish.
So thanks very much everyone for obviously supporting us. Balash, I really enjoyed that. It's one of my favourite topics, obviously a bit rusty now because I've, I've not been, doing it for the last 18 months, while I'm concentrating on webinar that, but.
Absolutely brilliant. It's so good to see you coming over, you know, bringing the gospel of cytology from, from Budapest and America. And I know how many residents that you've put through over the last few years.
You know, it's, it's so good, it's really good practise, I think, and it, it doesn't take the place of, histopathology, but I think sometimes doing the two things together will give you more chance of making the right decisions. Do you think, may I ask a question that if this gets uploaded where people can watch it later, do you think it would be possible to have a link there to the previous talk? Yes, I'm sure we'll put it in the same area, but we'll they should be able to find it, but we'll .
Stu, if you make a little note just to send to Catherine to make sure that we do that, but that would be great. And I think this is, this is a good area just to, you know, occasionally come back and and maybe even some case studies next time to see how if people have been listening. Yes, I was gonna offer you that if, if people are interested, I have lots of cases.
Develop with pictures where we can have polling questions, one after another after another, and then just go through cases after case after case you probably get good at it because this was obviously great, but it's when you're putting your reputation on the line, isn't it? Although anonymously, so nobody will know that that is a. That is always the test of whether you've really understood it or not.
So that would be great. I think we'll definitely take you up on that Balash. We are quite a way, we, we've done really well at getting ahead of ourselves, you know, in, in getting speakers in.
It just means that it might be even, the end of this year or next year before we do that unless we do something, but . No, that would be excellent. I'd, I'd really enjoy that.
So Balash, thank you once again, it has been brilliant. I've really enjoyed it. I know, everybody else seems to have done as well, so thank you very much for .
For, for coming and thanks to everyone for listening. Yeah It's a great pleasure. Thank you.
Thank you. Bye-bye. Bye bye.