Rates of condyloma and dysplasia in Papanicolaou smears with and without endocervical cells

Clinical parameters associated with absence of endocervical/transformation zone component in conventional cervical Papanicolaou smears

OBJECTIVE

To study clinical factors predicting the absence of endocervical/transformation zone (EC/TZ) components of conventional cervical Papanicolaou (Pap) smears.

MATERIALS AND METHODS

The medical charts of patients who received Pap smears between March 2006 and August 2006 in the hospital were reviewed. The results of their Pap smears were retrieved while their demographic and clinical information were obtained from the medical charts. After excluding 378 cases with incomplete demographic data and 1397 cases with a history of pelvic irradiation, pelvic malignancy, and hysterectomy, 5662 cases were enrolled for data analysis. The relationship between clinical parameters and the absence of EC/TZ component was analyzed by Pearson Chi-square tests with Yates continuity correction and binary logistic regression tests.

RESULTS

The incidence of satisfactory but absence of EC/TZ component was 8.7% (491/5662). Pregnancy increased the absence of EC/TZ component [odds ratio (OR}: 2.84, 95% confidence interval (CI): 2.14-3.77, p<0.0001]. Postpartum status and endocervical polyps decreased incidence (OR: 0.61, 95% CI: 0.38-0.98, p = 0.043 and OR: 0.33, 95% CI: 0.25-0.44, p<0.0001, respectively).

CONCLUSIONS

Pregnancy is the only clinical factor associated with increased incidence of absence of EC/TZ cells. For these pregnant women undergoing a Pap smear, a more effective strategy may be needed to get a satisfactory smear with adequate EC/TZ components.

The significance of endocervical cells and metaplastic squamous cells in liquid-based cervical cytology

We conducted a retrospective study to investigate whether the presence or absence of endocervical cells (EC) and metaplastic squamous cells (MSC) was associated with the detection of squamous intraepithelial lesions in liquid-based cervical cytology. 90,376 cases of liquid-based cervical cytology smears received in 2006 were included in the study. Low-grade (LSIL) and high-grade squamous intraepithelial lesions (HSIL) were classified according to the Bethesda system (2001). The rates of detecting LSIL and HSIL in smears with and without EC and/or MSC were determined. There were 1,540 LSIL and 396 HSIL. The ratio of HSIL/NILM (no intraepithelial lesion or malignancy) was 0.0022 in smears without EC or MSC, 0.0040 in smears with EC only, 0.0044 in smears with MSC only, and 0.0056 in smears with both EC and MSC present. Compared with smears without EC or MSC, this ratio was significantly higher (P < 0.05) when either EC or MSC was present. Compared with smears with EC only, the ratio was also significantly higher when both EC and MSC were present (P < 0.05). On the other hand, the presence or absence of EC had no effect on the detection rate of LSIL (0.0191 for both groups), while the presence of MSC was actually associated with lower detection rate of LSIL (0.0153, P < 0.05). The presence of endocervical and metaplastic cells was associated with higher detection rates of HSIL. MSC was associated with lower detection or LSIL.

ASCCP patient management guidelines: Pap test specimen adequacy and quality indicators

Our objective was to provide management guidelines according to Papanicolaou (Pap) test specimen adequacy based on literature review and expert opinion. A task force named by the American Society for Colposcopy and Cervical Pathology (ASCCP) conducted a literature review and discussed appropriate management. The Steering Committee of the ASCCP and other experts reviewed the guidelines. The guidelines recommend a repeated Pap test in 12 months for most women undergoing routine annual/biennial screening if the current Pap test is negative but either lacks an endocervical/ transformation zone component or is partially obscured. Indications for considering an earlier repeat are also provided. The preferred managementfor unsatisfactory Pap tests is a repeated Pap test within a short interval of 2 to 4 months. The management guidelines will help promote optimal and uniform follow-up of women according to Pap test specimen adequacy.

ASCCP Patient Management Guidelines: Pap Test Specimen Adequacy and Quality Indicators

OBJECTIVES

To provide management guidelines according to Pap test specimen adequacy based on literature review and expert opinion.

METHODS

A task force named by the American Society for Colposcopy and Cervical Pathology conducted a literature review and discussed appropriate management. The steering committee of the American Society for Colposcopy and Cervical Pathology and other experts reviewed the guidelines.

RESULTS

The guidelines recommend a repeat Pap test in 12 months for most women who are undergoing routine annual/biennial screening if the current Pap test is negative but either lacks an endocervical/transformation zone component or is partially obscured. Indications for considering an earlier repeat are also provided. The preferred management for unsatisfactory Pap tests is a repeat Pap test within a short interval of 2 to 4 months.

CONCLUSIONS

The management guidelines will help promote optimal and uniform follow-up of women's Pap tests, according to Pap test specimen adequacy.

Endocervical component: is it a determinant of specimen adequacy?

There is controversy in the literature concerning the presence or absence of an endocervical component as a determinant of the adequacy of cervical cellular samples. The purpose of this retrospective 2-yr study (January 1, 1999-December 31, 2000) was to evaluate the diagnostic accuracy of ThinPrep Pap Tests with the presence or absence of an endocervical component from 151 women with subsequent tissue-verified cervical intraepithelial neoplasia (CIN) II/III. Of the 138 Pap Tests containing an endocervical component, 100 (73%) showed exact cyto/histologic correlation and 38 (27%) were discordant. Of the 13 Pap Tests lacking an endocervical component, 10 (77%) showed exact correlation and 3 (23%) were discordant. Statistical analysis showed no significant difference in the detection of a high-grade squamous intraepithelial lesion (HSIL) in those ThinPreps that contained an endocervical component from those that did not (P > 0.5). Further analysis of the 41 discordant ThinPrep Pap Tests showed no significant difference between negative Pap Tests and discordant, yet abnormal Pap Tests (atypical squamous cells of undetermined significance, or low-grade squamous intraepithelial lesions) and the presence or absence of an endocervical component (P = 0.25). The results of this study seem to indicate that the issue of the lack of an endocervical component as a determinant of cervical specimen adequacy should be revisited.

Specimen adequacy and the ThinPrep Pap Test: the endocervical component

The ThinPrep Pap Test (Cyryc Corp., Boxborough, MA) has proven to be effective in decreasing the number of cervical specimens limited for interpretation by blood/inflammatory exudate as compared to conventional smears. However, its effectiveness in decreasing the number of preparations which lack an endocervical component is less well-established. The purpose of this 1-yr study (January 1998-December 1998) was to determine if the collecting instruments used by physicians played a role in the lack of an endocervical component on ThinPrep slides. On implementation of the ThinPrep Pap Test for cervical cytology, the broom-type sampling device (Papette, Wallach Surgical Devices, Inc., Millford, CT) was the FDA-approved collecting instrument. Subsequently the combined plastic spatula/Zelsmyr Cytobrush (Medscand, Inc., Hollywood, FL) were approved. A survey was sent to 102 physicians in seven primarY care sites and two private obstetrics-gynecology practices affiliated with the Loyola University Health Care System. One site used the broom only, one site used the spatula/cytobrush, five sites used the broom/cytobrush, and in two sites, two different sets of collecting instruments were utilized. Of the 10,241 ThinPrep samples, 620 (6%) were obtained with the broom only, 432 (4.3%) with the spatula/cytobrush, and 9,189 (89.7%) with the broom/cytobrush. An endocervical component was absent in 24% (range, 13.7-25%) of the cervical samples collected with the broom only, 10% (range, 8.4-12.5%) with the spatula/cytobrush, and 13% (range, 6.2-18.8%) with the broom/ cytobrush. The spatula/cytobrush and the broom/cytobrush showed statistical significance (P < 0.001) over the broom alone in the collection of an endocervical component. The results of this study indicate that the collecting instruments used by the physician(s) played a role in the adequacy (endocervical component) of the specimen processed by the ThinPrep method. Diagn. Cyto

Collection devices for obtaining cervical cytology samples

OBJECTIVES

The false-negative rate of cervical smears varies between 1.5% and 55%. This variation may be partly due to differences in sampling device and technique. The objective of this review was to assess different cervical sampling devices for collecting endocervical cells, which are thought to be a surrogate for detection of abnormal cells and adequate smear rates.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group trials register and MEDLINE up to July 1997. We also handsearched 16 journals.

SELECTION CRITERIA

Randomised and quasi-randomised trials and non-randomised comparative studies comparing cervical smear collection devices in women attending for primary screening, colposcopy following an abnormal smear or colposcopy after treatment.

DATA COLLECTION AND ANALYSIS

Two reviewers independently abstracted data. Study quality was assessed.

MAIN RESULTS

Thirty-four trials and six observational comparative studies were included. The Ayre spatula was shown to be less effective compared with extended tip spatulas for collecting endocervical cells in eight trials (odds ratio 2.25, 95% confidence interval 2.06 to 2.44). Use of a spatula with the cytobrush was more effective than spatula alone at collecting endocervical cells (odds ratio 3.33, 95% 3.05 to 3.63) and the same effect was present for adequate smear rates (odds ratio 1.51 95% 1.19-1.92). Extended tip spatulas were also superior for the detection of dyskaryosis in seven trials (odds ratio 1.21, 95% confidence interval 1.10 to 1.33). Based on data from two trials and three observational studies, smears that contained endocervical cells were more likely to detect dyskaryosis, particularly in severe disease. The proportion of smears with endocervical cells present increased with increasing severity of the disease.

REVIEWER'S CONCLUSIONS

Extended tip spatulas of various designs appear to be better for collecting endocervical cells than the commonly used Ayre spatula. The most effective combination appears to be the cytobrush with an extended tip spatula. The rate of detection of endocervical cells appears to be a valid and convenient surrogate for the ability to detect dyskaryosis and for adequate smear rates. The ability of the extended tip spatula with the cytobrush compared with the extended tip spatula alone to detect disease, needs to be evaluated in a trial.

Efficacy of cervical-smear collection devices: a systematic review and meta-analysis

BACKGROUND

Few randomised controlled trials have sufficient power to show clear advantages of different designs of cervical-smear collection devices. We studied by systematic review whether the design of cervical-smear devices affects rates of inadequate smears and detection of disease and whether the presence of endocervical cells in the smear affects detection of disease.

METHODS

We sought relevant randomised controlled trials by computer literature review by MEDLINE backed up by a manual search of 16 journals. Each trial was classified according to methodological quality criteria. Odds ratios were calculated where data allowed.

FINDINGS

34 randomised controlled trials investigating cervical Papanicolaou smear collection devices were identified. All 34 trials compared the ability of devices to collect endocervical cells, and 19 compared the ability of devices to detect dyskaryosis. Meta-analyses showed that compared with other collection devices, the Ayre's spatula is an ineffective device for collecting endocervical cells (for example, odds ratio for comparison of extended-tip spatulas vs Ayre's spatula 2.25 [95% CI 2.06-2.44]) and also gives a lower yield of dyskaryosis (odds ratio for comparison of extended-tip spatulas vs Ayre's spatula 1.21 [1.20-1.33]). Devices that effectively collect endocervical cells also detect a higher proportion of abnormal cytology than those that do not.

INTERPRETATION

The widely used Ayre's spatula is the least effective device for cervical sampling and should be superseded by extended-tip spatulas for primary screening and investigation of women before and after treatment for cervical intraepithelial neoplasia. The presence of endocervical cells is a valid and convenient surrogate for the ability to detect dyskaryosis.

Cancer diagnosis after a report of negative cervical cytology

OBJECTIVES

1. To determine the annual rate of interval squamous cancer of the cervix after a negative Papanicolaou smear report. 2. To evaluate the proportion of women with cervical cancer who received negative cervical smear reports during the three years before the cancer diagnosis.

DESIGN AND SETTING

Objective 1. A prospective study of the incidence of squamous cervical cancer from 1990 to 1993 among women who received negative cervical smear results in Victoria in 1990. Objective 2. A retrospective audit of preceding cervical smear results from 1990 to 1993 in women diagnosed with cervical cancer in Victoria in 1993.

RESULTS

The average interval cervical rate was 2.54 squamous cancers per 100000 women per year (95% confidence interval, 1.75-3.67) during the first three years after a negative smear report. The interval cancer rate did not vary by age group nor by the endocervical status of the negative smear report. Of the 233 cases of cervical cancer diagnosed during 1993, 56 women (24%) had negative cervical cytology reported during the preceding three years. The frequency of preceding negative cervical cytology was greater for non-squamous cancer (22 women [33%] from 66 cases) than for squamous cancer (34 women [20%] from 167 cases.

CONCLUSION

The rate of interval cancer diagnosis is very low compared with expected rates in the absence of screening, indicating the effectiveness of the cervical screening program in Victoria.

What are women told about Pap smears that lack endocervical cells?

BACKGROUND

Debate exists about the definition of what constitutes an adequate Pap smear and about the recommended rescreening interval for Pap smears lacking an endocervical component. This study aimed at determining whether women are currently informed about the endocervical status of their Pap smears and what rescreening recommendations are made to women whose smears lack endocervical cells.

METHOD

Consecutive Pap smears lacking an endocervical component were identified from pathology records. After obtaining consent from the referring doctor, 165 women were interviewed by telephone.

RESULTS

Only 110 (67%) of 165 women received active notification of their Pap test result and only six (4%) were aware that their smear lacked endocervical cells. Thirteen (8%) had been advised to have a repeat smear within three months. Nearly half the women reported that they would like more information about their result.

CONCLUSIONS

It seems that current Pap smear notification patterns for women in New South Wales could be improved. One third are not actively informed at all about their results, and few are given detailed information about their Pap test results. Methods of enhancing the level of information women are given about their medical and screening tests need to be improved.

Cellular differences between true negative and false negative Papanicolaou smears

A matched case-control study of 123 false negative Papanicolaou smears and 488 true negative Papanicolaou smears was undertaken to determine the association between the types of cells present on the smear and the correctness of the cytology report. The false negative slides were significantly more likely to include endocervical columnar cells than the true negative slides (odds ratio 1.90, 95% confidence interval (CI) 1.21-3.01). No statistically significant difference in metaplastic cell status was evident (odds ratio 1.48, 95% CI 0.95-2.30). When considered together, metaplastic and/or columnar cells were significantly more likely to be present in false negative smears than in true negative smears (odds ratio 1.87, 95% CI 1.13-3.08). The implications of these findings for improving the accuracy of cervical cytology for the detection of precancerous lesions are discussed.

Specimen adequacy evaluation in gynecologic cytopathology: current laboratory practice in the College of American Pathologists Interlaboratory Comparison Program and tentative guidelines for future practice

Routine specimen adequacy evaluation, as advocated by The Bethesda System (TBS), can play an important role in improving the sensitivity and accuracy of cervical cytopathology screening. The effectiveness of this measure, however, has been limited by the lack of uniform criteria for adequacy. Practice parameters are now emerging, through TBS development of tentative criteria and interlaboratory comparison of adequacy practices. This study reviews 1) nationwide responses to surveys of laboratory practices in the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology (CAP PAP); 2) the definitions of adequacy based on TBS; and 3) the results of implementation of these criteria in a private independent laboratory, university hospital laboratory, and private nonprofit hospital laboratory. In the initial CAP PAP survey in 1990, 35% of responding laboratories routinely reported specimen adequacy, increasing to 66% in 1991 and 85% in 1992. Interlaboratory variations in adequacy practices were observed, however, underscoring the need for consensus criteria. The experience in the authors' laboratories indicates that TBS criteria can serve as a sound guideline. Effective implementation of adequacy assessment in the individual laboratory requires careful attention to ensuring the quality of adequacy ratings, correlating clinical and prior laboratory information, issuing clear and concise reports, and giving recommendations judiciously. Through interlaboratory comparison and consistent intralaboratory emphasis on specimen adequacy, greater uniformity of adequacy assessment can be achieved, and adequacy evaluation can achieve its promise of improving the quality of cervical cytopathology.

Cytological reporting of cervical abnormalities according to endocervical status

An analysis of cytology reporting within Victorian Cytology Service demonstrates that the proportion of Papanicolaou smears which were reported as including an endocervical component increased from approximately one half during 1987-89 to more than three quarters during 1990-91. The improvement coincided with the routine provision of special sampling instruments to all practitioners supplemented by an education program. Despite the increase in endocervical sampling, no increase in the rate of reporting of high-grade intraepithelial lesions of the cervix has occurred. An increase between the two time periods in the cytological reporting of adenocarcinoma, adenocarcinoma in situ and endocervical dyskaryosis has occurred, but does not reach statistical significance.

Should we report cervical smears lacking endocervical component as unsatisfactory?

The purpose of the study is to correlate the accuracy of diagnosis of cervical smears with the presence/absence of an endocervical component. The referral smears and the smears obtained during colposcopic examination of 84 patients with biopsy-proven squamous lesions were evaluated for the presence of an endocervical component, and the cytologic interpretations were compared with the histologic findings. Of the 136 smears containing an endocervical component, 111 (81.6 percent) had good correlation with histology and 25 (18.4%) showed a discrepancy. Of the 30 smears lacking an endocervical component, 24 (80%) had good histologic correlation and 6 (20%) were discrepant. Our data showed no significant difference in the detection of squamous lesions in those smears with an endocervical component from those without. We conclude that, although the presence or absence of an endocervical component should be documented in the cytology report, its absence should not be an indication to report the cervical smears as unsatisfactory.

The determination of Papanicolaou smear adequacy using a semiquantitative method to evaluate cellularity

To examine the influence of sample cellularity and the presence of endocervical columnar cells on the detection of cervical dysplasia, Papanicolaou (Pap) smears taken from patients with biopsy-proven CIN II and III were analyzed retrospectively. Adequacy was semiquantitated by dividing each smear into 15 equal areas using a lined template and assigning an adequacy index (AI) of 0 to 15. The total false-negative (FN) rate was 15.8 percent, with 6.1% representing interpretive error and 9.7% representing sampling error. For FN slides truly lacking abnormal cells, the average AI was significantly lower than that of true positives (TP), even when endocervical columnar cells were present. The entire group was then blindly re-evaluated using a subjective application of the Bethesda System, classifying slides as satisfactory, less than optimal, and unsatisfactory. Although correlation of AI with the rapid Bethesda System categorization was imperfect, the exclusion of less than optimal and unsatisfactory smears also lowered the FN rate, but less effectively. An AI scoring technique, therefore, may be useful in the routine evaluation of Pap smear adequacy.

Longitudinal study of women with negative cervical smears according to endocervical status

A longitudinal study of 20,222 women who received negative cervical smear reports in 1987 showed that the incidence of definite or equivocal cervical intraepithelial neoplasia (CIN) was not significantly different between those whose first smear lacked an endocervical component and those whose smear included an endocervical component. The incidence of definite cytological evidence of CIN was significantly lower in women whose first smear did not include an endocervical component. It is concluded that women whose smears are reported as negative but lack an endocervical component should not be rescreened any earlier than women with negative smears that include an endocervical component.

Prevalence of genital human papillomavirus infections in a mass-screened Finnish female population aged 20-65 years

The results of the nationwide, population-based cervical cancer screening programme (organized by the Finnish Cancer Society since early 1960s) were analysed to establish the prevalence figures (and their changes) for genital human papillomavirus (HPV) infections in an unselected Finnish female population (aged between 20 and 65 years) screened in Kuopio Province between 1981 and 1989. During the study period 82,393 women were invited on a regular basis for the mass-screening, and also 4131 women in a risk group. Of these, a total of 63,115 and 3249 women attended, resulting in the attendance rates of 76.6% and 78.6%, respectively. As a result of the screening, a total of 509 (0.80%) of the 63,115 smears were diagnosed as having the cytological changes consistent with HPV infection in the mass screening. The corresponding figures in the risk group screening were 58/3249 (1.78%). There was a sharply increasing trend in the prevalence of genital HPV infections from 1981 through 1987, from 0.04% to 1.76% (ie a 44-fold increase in 7 years) which, surprisingly, then declined to 1.43% in 1988 and 1.04% in 1989. Based on a random sample of 2084 routine (non-mass-screening) Pap smears (out of (28,861) collected from the files of our laboratory, the prevalence of HPV infections was stratified by age groups. The highest prevalence (6.1%) was observed in women aged between 20 and 29 years, followed by 2.2% in those aged 30-39 years. Using the figures of the relative risk (RR) of HPV infections by age, an estimation was made to assess the prevalence of clinical HPV infections in the Finnish female population in general.(ABSTRACT TRUNCATED AT 250 WORDS)