EUS and EUS-FNA diagnosis of suspected pancreatic cystic neoplasms: Is the sum of the parts greater than the CEA?

BACKGROUND

Carcinoembryonic antigen (CEA) is suggested as the single most useful EUS/EUS-FNA derived test for the diagnosis of mucinous pancreatic cysts.

STUDY AIMS

To investigate the yield and diagnostic performance of EUS/EUS-FNA on an intention to diagnose basis and to determine the utility of the recommended CEA and amylase cut-off values.

PATIENTS AND METHODS

A retrospective study of a prospectively maintained database of 433 procedures performed in a 10 year period. Diagnostic performance of EUS-FNA was determined in 133 procedures with a definite diagnosis.

RESULTS

CEA value was determined in significantly fewer procedures (58.6%) than EUS diagnosis was stated (83.4%; p < 0.0001), cyst fluid appearance recorded (89.4%) or adequate sample for cytology obtained (76.7%; p < 0.005). Median CEA was significantly higher in mucinous cysts than non-mucinous (175 ng/ml vs 3 ng/ml, p < 0.0001) and in malignant cysts compared to benign (8945 ng/ml vs 93 ng/ml, p < 0.001). On an intention-to-diagnose analysis, a CEA cut-off of 110 ng/ml was significantly less accurate (42.8%) than EUS diagnosis (67.7%), cytology (58.6%) or aspirate appearance (66.9%; p < 0.05 for all comparisons). However, the combination of EUS diagnosis, cytology and CEA provided higher sensitivity (91%), specificity (75%) and accuracy (85.7%) than each component test alone (p < 0.05 for all comparisons). Median amylase was significantly higher in benign compared to high-risk mucinous cysts ((11,429IU/L vs. 113IU/L; p < 0.05.

CONCLUSION

The combination of EUS, cytology and CEA performed well. Malignant cysts had a higher CEA value than benign cysts. On an intention to diagnose basis a CEA cut-off of 110 ng/ml performed poorly.

Remote and rapid pathological diagnosis in a resource challenged unit

Malawi is one of the world's poorest countries, but despite this, has a dedicated paediatric oncology service. The service has been hampered by the inability to make a timely cytological diagnosis in the majority of patients. A telemedicine programme was commenced to help overcome this problem, and the results for the first 197 consecutive patients are described. The results are compared with the local reports where available. Most samples were fine needle aspirates (104/197-53%), but others included bone marrow aspirates, peripheral blood films and other fluid collections. A diagnosis was arrived at in 52% of the samples; there were 46 discordant results, 38 were when one or other of the local or distant teams were unable to make a diagnosis, and only 8 where the diagnoses of the 2 teams differed. Diagnoses were made and reports were compiled by the 'distant' team within 24 h and sent to the centre in Malawi. This simple telepathology initiative has had a positive impact on clinical management, and could be used in other less resourced centres twinned with better resourced ones.

Colposcopic management of high-grade referral smears: a retrospective audit supporting 'see and treat'?

OBJECTIVE

The National Health Service Cervical Screening Programme monitors the quality of colposcopy services through the annual KC65 returns. The 2002 returns demonstrated that Standard 7c, which specifies a biopsy rate > or = 90% at first colposcopy visit for high-grade referrals, was not met in the assessed 3-month period. This was investigated along with the other standards.

METHODS

Retrospective colposcopy records were accessed for the 597 new referrals, excluding 10 pregnant patients, seen at the colposcopy clinic at the Royal Victoria Infirmary between 1 July 2001 and 31 December 2002, following an abnormal high-grade smear. Cytology and histopathology computer records were checked for confirmation. The results were assessed against the colposcopy standards applicable at that time and the revised standards (2004).

RESULTS

Biopsies were taken from 94.47% (Standard > or = 90%) of women at index colposcopy visit including wire loop excision biopsies from 66.16% (87.97% of high-grade colposcopic appearances). Cervical intraepithelial neoplasia (CIN) on histology was found in 91.79% in the study group (Standard > or = 85%) and in 96.71% of index visit biopsies (Standard > or = 90%), meeting the applicable colposcopy standards. The revised 2004 standards specify a biopsy in > or = 95% of high-grade referrals and excision biopsies in 95% if colposcopic appearances are also high-grade, if colposcopy is low grade but the smear is severely dyskaryotic, or when the lesion extends into the canal. The positive predictive value of high-grade cytology for this entire group was 75.54% with CIN present in 90.95%.

CONCLUSION

From this study it appears that high-grade cytology in this centre reliably indicates high-grade CIN. Therefore, in women referred for colposcopy following a high-grade smear, excision biopsies should be performed in a higher proportion at the first visit to comply with the revised standards.

Ultrasound guidance improves the adequacy of our preoperative thyroid cytology but not its accuracy

AIMS

Our thyroid cytology audit results of 1990-1995 showed an unsatisfactory rate of 43.1% and prediction of neoplasia with a sensitivity of 86.8%. Increasingly, ultrasound scan (USS)-guided core sampling for cytology is proving a valuable tool instead of freehand fine needle aspiration (FNA) or following unsatisfactory freehand FNA. We present the results of freehand FNA and USS-guided core samples for cytology in two separate patient groups in our centre.

METHODS

Patients who had a thyroid resection and preoperative thyroid cytology in our institution between 1996 and 2002 were included. The histological diagnoses were correlated with the preceding cytology results.

RESULTS

A total of 450 FNAs were performed on 394 patients. Freehand FNAs were performed for 348 (77.3%) samples and USS-guided core for 102 (22.7%) samples; 121 (26.8%) were repeat aspirates performed on 45 patients. Using aspiration cytology (AC) grading, freehand FNA was cytologically inadequate (AC0 or AC1) in 34.8% cases whereas USS-guided core was inadequate in 17.6% cases (P = 0.001). Freehand FNA (AC3, AC4, AC5) predicted neoplasia with a sensitivity of 83.2%, specificity of 46.6%, accuracy of 63.0%, positive predictive value of 56.0% and negative predictive value of 77.1%. USS-guided core sample for cytology (AC3, AC4, AC5) predicted neoplasia with a sensitivity of 93.5%, specificity of 26.0%, accuracy of 51.9%, positive predictive value of 43.9% and negative predictive value of 86.7%.

CONCLUSIONS

Although USS-guided core provides more satisfactory specimens than freehand FNA, in our centre it does not provide increased accuracy.

Subtyping borderline nuclear changes: is it of value in predicting high-grade cervical intraepithelial neoplasia on histology?

The aim was to determine the association between the subtypes of borderline nuclear changes (BNC) in cervical smears and high-grade cervical intraepithelial neoplasia (HCIN). BNC was reported in 23236 smears received in our laboratory over a 7-year period, 3278 patients were referred for colposcopy. Analysis was restricted to 2007 cases, which fitted the criteria of: (1). consistent subtyping of borderline change and (2). cervical histology result within 12 months of the last abnormal smear. BNC was reported in six categories and correlated with histology. Atypia bordering on dyskaryosis, atypical metaplastic cells and endocervical atypia, were associated with HCIN in 25%, 25.4% and 23.8% of cases, respectively. Dyskeratosis and koilocytotic atypia were associated with HCIN in 19.2% and 13.7% of cases, respectively. Some subtypes of borderline change are more frequently associated with HCIN. The difference is not sufficient to dictate clinical management.

An audit of the positive predictive value of high-grade dyskaryosis in cervical smears: 2001-2002

The positive predictive value (PPV) of high-grade dyskaryosis for cervical intraepithelial neoplasia grade 2 (CIN2) or worse on histology is published annually for the laboratories in the UK National Health Service Cervical Screening Programme (NHSCSP). The PPV fell in 2001 compared with 2000 for four of the five consultants reporting cervical smears in our laboratory, the greatest fall being from 91.6% to 77.9%. Investigation of the possible reasons for the fall suggested the main cause lay outside the laboratory in the type of biopsy taken at colposcopy. We conclude that biopsy type affects accuracy of PPV calculations. There is variation in collection and submission of KC61 data including PPV across laboratories. This factor needs to be taken into account when publishing and comparing laboratory data for the NHSCSP.

Management of stable angina

Ischaemic heart disease may present as a wide variety of clinical entities including unstable or stable angina pectoris, acute myocardial infarction, and occasionally heart failure. Chronic stable angina is a common condition and results in a considerable burden for both the individual and society. The goals in management are (i) treatment of other conditions that may worsen angina; (ii) modification of risk factors and treatment with medications for coronary artery disease to improve outcome; and (iii) effective relief of anginal symptoms. There are limitations to the methods available to risk-stratify patients, and the optimal treatment strategy remains unclear. The benefits of lifestyle modification cannot be over-emphasised, and appropriate attention to modifiable risk factors is paramount. The mortality benefit of lipid lowering treatment and antiplatelet therapy is well proved. However the evidence base for anti-ischaemic therapy is less rigorous, being based mainly on extrapolations from studies of acute coronary syndromes. Angioplasty has been shown to be more effective in relief of symptoms than medical therapy alone, but provides no mortality benefit. Coronary artery bypass surgery, however, has been shown to reduce mortality in patients with severe proximal coronary disease when compared with medical management alone.

How predictive is a cervical smear suggesting glandular neoplasia?

The prevalence of endocervical adenocarcinoma and its precursors has increased, in part due to increased diagnostic awareness of these lesions. To date, limited information has been published regarding the predictive value of glandular abnormalities in cervical smears. This study details the histological follow up of 418 cervical smears showing glandular abnormality, reported in our department over a six year period from 1993 to 1998. Histological follow up was available for 395 of the 418 smears (94.50%). The overall positive predictive value (PPV) for this group of smears was 72.66% for either significant glandular or squamous pathology (at least low grade cervical glandular intraepithelial neoplasia or CIN2 on follow up biopsy), and 55.70% for significant glandular pathology alone. Examination of subcategories of abnormal glandular smear showed that the PPV increased with the degree of abnormality reported within the smears.

How predictive is a cervical smear suggesting invasive squamous cell carcinoma?

How predictive is a cervical smear suggesting invasive squamous cell carcinoma? Features have been described in severely dyskaryotic cervical smears that suggest frankly invasive or microinvasive squamous cell carcinoma. These are reported in three separate categories in our department. The aim of the current study was to assess the positive predictive value of these categories for invasive disease on histology. All smears reported in these categories over a five year period were correlated with the histology results. 527 smears were assessed. The positive predictive value of a smear suggesting frank invasion was 55.7% for all invasive squamous carcinomas and 40% for stage IB or above. Smears suspicious of invasion or microinvasion predicted invasive disease in 22.3% and 17.2%, respectively, most carcinomas being stage IA. Invasive squamous cell carcinoma may be predicted to a limited degree by cervical cytology especially when the smear suggests frank invasion.

The importance of intracytoplasmic DPAS positivity in fine needle aspirates of breast lesions

AIMS

For many years the presence of strong intracytoplasmic periodic acid Schiff (PAS) positive, diastase resistant (DPAS) staining within atypical cells has been used in this laboratory as a marker for carcinoma in fine needle aspirates from breast lesions. The aim of the current study was to document such DPAS positivity across the spectrum from benign to malignant breast disease and assess its value in the upgrading of cytology reports.

METHODS

Over a six month period, 315 aspirates were studied, each having sufficient cellular material for DPAS staining to be carried out on one whole slide. DPAS staining was recorded semiquantitatively as negative, equivocal, or positive (+, ++, or +++). The cytology results were correlated with any subsequent histology performed on these patients.

RESULTS

DPAS positive material was seen in both intracellular and extracellular locations. Care was needed in its interpretation. Occasional cells with apparently genuine intracytoplasmic positivity (+) were found in both benign and malignant cases. Frequent or particularly strong intracellular DPAS positivity (++, +++) correlated best with malignancy. Two cases were reliably upgraded from immediate reports suspicious of malignancy to final reports diagnostic of malignancy on the basis of the intracytoplasmic DPAS staining.

CONCLUSION

Strict criteria are required for the interpretation of intracytoplasmic DPAS positivity and routine cytological appearances should also be taken into account. Weak positivity in occasional cells, especially in flat epithelial sheets, may be seen in benign lesions and is not reliable as a marker of malignancy. DPAS positivity with internal structure and producing nuclear indentation, especially in dissociated or atypical cells, correlates well with malignant histology and can be reassuring in the cytological diagnosis of malignancy.

Laparoscopic peritoneal lavage cytology and immunocytology in pancreatic and periampullary carcinoma

BACKGROUND

Free tumour cells in the peritoneal cavity of patients with pancreatic carcinoma carry a poor prognosis. Reactive or degenerative mesothelial cells can make cytological interpretation with conventional stains difficult. Detection of the tumour-associated antigens carcinoembryonic antigen (CEA) and CA19-9 may improve detection.

METHODS

At staging laparoscopy, 22 patients with pancreatic or periampullary tumours had ascitic fluid aspirated or peritoneal lavage performed. Both conventional and immunocytologically stained preparations were examined. Antibodies to CEA and CA19-9 and the epithelial marker BerEP4 were used. Lavage fluid from ten patients having operative treatment for benign pancreatic or biliary conditions was also examined.

RESULTS

No malignant cells on conventional cytological criteria were recovered.Thirteen of the 22 patients with pancreatic or periampullary carcinoma had peritoneal cells that were positive for CEA and/or CA19-9. None was positive for BerEP4. No patients with resectable disease had cells that were positive for CEA or CA19-9 compared with 13 of 18 (72%) who had unresectable disease. One patient (10%) with benign disease (chronic pancreatitis) had cells recovered that were weakly positive for CEA but negative for CA19-9 and BerEP4.

DISCUSSION

Recovery of cells from the peritoneal cavity of patients with pancreatic or periampullary carcinoma that are expressing the tumour-associated antigens CEA or CA19-9 does not indicate the presence of free tumour cells but is associated with advanced disease.

Thyroid aspiration cytology in Newcastle: a six year cytology/histology correlation study

BACKGROUND

Fine needle aspiration cytology (FNAC) is a well-established technique for pre-operative investigation of thyroid nodule(s). Thyroid FNAC was introduced in the teaching hospitals of Newcastle upon Tyne in 1981, initially with a small group of clinicians as aspirators. Audit results for 1981-1986 inclusive showed an unsatisfactory rate of 25.3% and prediction of malignancy with a sensitivity of 93.5%. FNAC has become more popular locally for the investigation of thyroid disease and the number of clinicians performing aspirates has increased. The results for recent years have, therefore, been audited.

METHODS

Medical records were reviewed for 239 patients with a dominant thyroid nodule who had FNAC carried out in the 6 year period 1990-1995 and subsequent partial or complete thyroidectomy.

RESULTS

Histology of thyroid specimens showed 60 follicular adenomas and 34 malignant lesions (including 19 papillary, 10 follicular and 3 medullary carcinomas, one lymphoma and one follicular neoplasm with indeterminate malignant potential). A total of 302 FNAC had been carried out on these 239 patients. On cytological grounds the unsatisfactory sample (AC0 and AC1) rate was 43.1% on initial aspiration which was reduced to 32.2% on repeated aspiration. FNAC predicted neoplasia (AC3, AC4 and AC5) with a sensitivity of 86.8%, a specificity of 67.0%, a negative predictive value of 87.5% and a positive predictive value of 65.5%. Malignancy was predicted by FNAC (AC3, AC4 and AC5) with a sensitivity of 88.9%. A FNAC report of AC5 had a positive predictive value for malignancy of 100%.

CONCLUSIONS

FNAC is an invaluable and minimally invasive procedure for the pre-operative assessment of patients with a dominant thyroid nodule. It is, however, important that the number of aspirators and cytopathologists be kept small to maintain expertise and also that the results of FNAC be subjected to ongoing audit.

DNA ploidy and cell cycle distribution of breast cancer aspirate cells measured by image cytometry and analyzed by artificial neural networks for their prognostic significance

Chromosomal abnormalities are commonly associated with cancer, and their importance in the pathogenesis of the disease has been well recognized. Also recognized in recent years is the possibility that, together with chromosomal abnormalities, DNA ploidy of breast cancer aspirate cells, measured by image cytometric techniques, may correlate with prognosis of the disease. Here, we have examined the use of an artificial neural network to predict: 1) subclinical metastatic disease in the regional lymph nodes and 2) histological assessment, through the analysis of data obtained by image cytometric techniques of fine needle aspirates of breast tumors. The cellular features considered were: 1) DNA ploidy measured in terms of nuclear DNA content as well as by cell cycle distribution; 2) size of the S-phase fraction; and 3) nuclear pleomorphism. A further objective of the study was to analyze individual markers in terms of impact significance on predicting outcome in both cases. DNA ploidy, indicated by cell cycle distribution, was found markedly to influence the prediction of nodal spread of breast cancer, and nuclear pleomorphism to a lesser degree. Furthermore, a comparison between histological assessment and artificial neural network prediction shows a closer correlation between the neural approach and the development of further metastases as indicated in subsequent follow-up, than does histological assessment. These data demonstrate that artificial neural networks are capable of providing powerful and reliable indicators of possible lymph node metastasis, using measurements of cellular features alone.

Peritoneal cytology in the surgical evaluation of gastric carcinoma

Many patients undergoing surgery for gastric carcinoma will develop peritoneal metastases. A method to identify those patients at risk of peritoneal recurrence would help in the selection of patients for adjuvant therapy. Peritoneal cytology has received little attention in the West, but may prove a useful additional means of evaluating patients with gastric cancer. The aims of this study were to evaluate sampling techniques for peritoneal cytology in patients with gastric cancer, to assess the prognostic significance of free peritoneal malignant cells and to discover the effect of the operative procedure on dissemination of malignant cells. The study is based on 85 consecutive patients undergoing surgical treatment of gastric cancer and followed up for 2 years or until death. Peritoneal cytology samples were collected at laparoscopy, and at operation prior to resection by intraperitoneal lavage and serosal brushings. After resection, samples were taken by peritoneal lavage, imprint cytology of the resected specimen and post-operatively by peritoneal irrigation via a percutaneous catheter. Malignant cells were diagnosed by two independent microscopists. Preoperative peritoneal lavage yielded malignant cells in 16 out of 85 cases (19%). The yield of free malignant cells was increased by using serosal brushings (by four cases) and imprint cytology (by two cases); all of the cases had evidence of serosal penetration. One serosa-negative case exhibited positive cytology in the post-resection peritoneal specimen in which the preresection cytology specimen was negative. Survival was worse in the cytology-positive group (chi2 = 25.1; P< 0.0001). Among serosa-positive patients, survival was significantly reduced if cytology was positive, if cases yielded by brushings and imprint cytology were included (log-rank test = 8.44; 1 df, P = 0.004). In conclusion, free peritoneal malignant cells can be identified in patients with gastric cancer who have a poor prognosis; the yield can be increased with brushings and imprint cytology in addition to conventional peritoneal lavage. Evaluation of peritoneal cytology by these methods may have a role in the selection of patients with the poorest prognosis who may benefit most from adjuvant therapy.

A prospective follow up study of women with colposcopically unconfirmed positive cervical smears

OBJECTIVE

To examine a cohort of women with positive cervical smears, but negative colposcopy, in order to ascertain whether there is a subsequent difference in the incidence of squamous dyskaryosis and cervical intraepithelial neoplasia when compared with a control group.

DESIGN

Prospective follow up study.

SETTING

Colposcopy clinics, antenatal clinics, GP surgeries.

METHODS

A study group of 255 women with reported abnormal cervical smears but negative colposcopy was subdivided into three groups according to referral smears suggesting high grade dyskaryosis (n = 34), mild dyskaryosis (n = 120) and borderline changes (n = 101). They were followed for at least five years and were compared with a control group of 726 women followed up after a negative smear, using the first and worst follow up smears over a five year recall period.

MAIN OUTCOME MEASURES

Incidence of subsequent cervical cytological and histological abnormalities.

RESULTS

The control group had a similar incidence of squamous dyskaryosis as that expected in the screening population. Forty-six per cent of the study group with colposcopically unconfirmed ('false positive') cervical smears subsequently had abnormal smears. When the three groups were compared with controls using a chi2 test, their incidence of abnormal smears was significantly increased. Cervical intrepithelial neoplasia was found in 19% of the study group, and in 3% of the control group (P < 0.0001).

CONCLUSIONS

The analysis demonstrates that women with so-called 'false positive' smears defined by negative colposcopy have an increased risk of subsequent abnormal smears and cervical intrepithelial neoplasia, suggesting that lesions may have been missed on colposcopy. However, in a significant proportion of women, further abnormalities were not detected during the follow up period, indicating that there may be other causes for positive smears and negative colposcopy.

Analysis of image cytometry data of fine needle aspirated cells of breast cancer patients: a comparison between logistic regression and artificial neural networks

Image flow cytometry data of aspirated tumour cells from 102 patients with breast cancer were analysed and used as prognostic markers in an attempt to predict involvement of axillary lymph nodes and histological grade using logistic regression. Prediction was 70% for both nodal status and histological analyses. The outcome of this study is compared to an earlier study using the same cytological information to obtain prediction using a neural approach. Using artificial neural networks, prediction accuracy was 87% and 82% for nodal status and histological assessment, respectively. This study also attempts to identify the impact of individual prognostic factors. The statistical approach identified S-phase fraction and DNA-ploidy as the most important prediction markers for nodal status and histological assessment analyses. A comparison was made between these two quantitative techniques.

The effects of different sampling techniques on smear quality and the diagnosis of cytological abnormalities in cervical screening

A major cause of false-negative cervical smear is sampling error. We examined the results obtained with three different instruments in 126,608 smears from general practitioners. The spatula/brush combination yielded the highest proportion of smears showing cytological abnormalities, and the Cervex brush the lowest. Although not a randomized study, this paper highlights the shortcomings of the Cervex brush. We postulate a mechanical deficiency. Diagnostic accuracy rather than a high proportion of good quality smears should dictate the choice of instrument.

A prospective evaluation of cytology from biliary strictures

BACKGROUND

Bile duct strictures may be benign or malignant. A definite diagnosis is desirable to advise patients of their prognosis and to identify any amenable to curative surgery.

AIMS

To compare different methods of cytology sampling from biliary strictures and evaluate the use of cytology in this context.

PATIENTS AND METHODS

In a prospective study 54 patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) had cytology samples obtained as follows: (1) biliary stricture brushings, (2) from the screw thread of a "Soehendra stent retriever" inserted through the stricture, (3) from the proximal end of a blocked biliary stent, and (4) cellular material spun down from a 20 ml specimen of bile. Examination of slides and rinsings was performed by an expert cytologist who graded them for the adequacy of the sample and for evidence of malignancy.

RESULTS

Prolonged follow up disclosed malignancy in 52 of the 54 cases, the other two being chronic pancreatitis. Bile samples provided adequate cytology samples in 44%, the Soehendra stent retriever in 70%, retrieved stents in 84%, and cytology brush sampling in 96%. Overall, 28 malignancies were detected by cytology, including 14 of 28 pancreatic carcinomas and 12 of 16 cholangiocarcinomas. Twenty two of the malignancies were detected by brush sampling and the other methods added a total of another six cases.

CONCLUSIONS

Cytology sampling is best done by brushing the biliary stricture. Cytology sampling can confirm the diagnosis in 75% of cholangiocarcinomas and 50% of pancreatic carcinomas. The techniques involved are simple to perform and should be routine clinical practice whenever potentially malignant biliary strictures are encountered at ERCP.

Rapid screening of cervical smears as a method of internal quality control. For how long should we rescreen?

OBJECTIVE

To compare the effectiveness of rapid screening of cervical smears as a method of internal quality control with 10% random rescreening.

STUDY DESIGN

From June 5 to July 14, 1995 (6 weeks), all consecutive cervical smears received in the department (n = 8,800) were entered into the study and were prescreened for a duration of 30 seconds (n = 2,938), 1 minute (n = 2,925) or 2 minutes (n = 2,937) over a period of 2 weeks each.

RESULTS

Rapid screening of all negative and unsatisfactory smears detected more cytologic abnormalities than would be expected with 10% random rescreening. Thirty-second rapid screening of all negative and unsatisfactory smears was more efficient in detecting false negatives than screening a proportion of the smears for longer periods of time. Rapid screening was also a very effective method of detecting severe cytologic abnormalities in unscreened smears, detecting over 90% of high grade lesions.

CONCLUSION

Rapid rescreening of negative and unsatisfactory cervical smears is recommended as a very effective method of internal quality control. It is superior to 10% random rescreening in reducing the false negative rate. Thirty-second rapid rescreening is the most efficient period for which smears should be screened. Rapid screening of unscreened smears could be used as a means of selecting patients for prompt referral when a laboratory backlog exists.

Quality grading for cervical smears

Three thousand five hundred and eighty cervical smears were taken in 1990-1992 at a Genitourinary Medicine Clinic with various spatula or spatula brush combinations. The unsatisfactory rate and the detection of cellular abnormalities showed some relation to spatula type. However, the satisfactory smears screened in the laboratory are routinely assigned a quality grade-good, fair or poor. Analysis shows higher rate of detection of cellular abnormalities in good quality smears, the detection of dyskaryosis being twice as high, in contrast to the fair or poor quality smears. It is suggested that quality grade is a better way of classifying smear quality in the cervical screening programmes rather than the presence or absence of endocervical and/or metaplastic cells.

Influence of smear quality on the rate of detecting significant cervical cytologic abnormalities

OBJECTIVE

To determine the correlation between cervical smear quality and the rate of detecting significant epithelial abnormalities.

STUDY DESIGN

Smear quality was assessed routinely in a series of 68,328 cervical spatula and spatula/brush combination smears received by our laboratory during 1993. Quality was assessed using a semiquantitative method, evaluating the presence of endocervical cells, metaplastic squamous cells, endocervical mucus and overall squamous cellularity.

RESULTS

Smear quality was graded as unsatisfactory, poor (18,680 smears), fair (9,739 smears) or good (39,909 smears); unsatisfactory smears were eliminated from the analysis. There was a highly significant correlation between smear quality and the rate of detecting significant epithelial abnormalities (chi 2=127.52, df=2, P<.001).

CONCLUSION

Smear quality is an important issue. Many significant abnormalities are potentially missed because of poor smear quality.

A medical audit and patient survey of hysterectomies performed for menstrual disorders

The aim of the study was to carry out an audit of 283 hysterectomies performed for menstrual disorders over a one year period, and to determine the satisfaction of the women concerned towards their treatment. The medical records of these patients were examined, and they were each sent a questionnaire, 69% of which were completed and returned. The most common presenting symptoms were menorrhagia and dysmenorrhoea. In 53% of cases no clinical abnormality was postulated and in 31% of cases no pathological abnormality was found. The preoperative clinical and pathological diagnoses were in agreement for 59% of patients. Over 90% of women were satisfied with the management of their case by their GP and the gynaecology outpatient clinic. The use of patient-controlled analgesia systems was associated with better post-operative pain relief than intramuscular injections. Thirteen percent of patients required blood transfusion; 21% suffered some form of postoperative complication, most of which were minor. Ninety-four percent of the women were pleased that they had undergone hysterectomy, and 76% wished that they had had the operation sooner. It was concluded that hysterectomy is perceived positively by patients and should not necessarily be considered as a last resort treatment for menstrual disorders.

An assessment of partial rescreening as an internal quality control method for cervical smears

Partial screening was performed on 10,800 cervical smears, comprising 8640 filed negative and unsatisfactory smears and 2160 newly received smears prior to conventional screening. Each slide was screened for 30 s and those considered abnormal were reviewed by standard screening. Partial screening led to the detection of 27 additional infections and 44 additional cytological abnormalities. These detection rates are better than those obtained with the traditional method of rescreening only a proportion of smears. Amongst the smears partially screened before conventional screening, partial screening detected 37-66% of infections and 22-71% of cytological abnormalities. We recommend the use of partial rescreening of all negatively reported smears as a method of internal quality control in cervical cytology laboratories.

p53 immunostaining as a marker of malignancy in cytologic preparations of body fluids

The accurate identification of suspicious cells in cytologic preparations is a common problem in diagnostic cytopathology. Recent studies have shown that mutation of the p53 gene may be the most common genetic event in human malignancy. Mutation leads to altered conformation and increased half-life of the p53 protein, resulting in detectability by immunocytochemistry. The usefulness of p53 immunocytochemical staining as a marker of malignancy in the cytologic analysis of body fluids was investigated in the present study. One hundred fifty-four serial samples of body fluids submitted for cytologic diagnosis were also examined for p53 immunoreactivity. Of 121 cases reported as cytologically benign, 3 (2.5%) stained positively for p53; 16 samples were cytologically malignant, and 7 (43.7%) of these were positive for p53 (P < .001). Of those reported as suspicious but not conclusively malignant, 4 of 17 (23.5%) showed p53 immunoreactivity. On review, two of the three patients whose samples were benign cytologically yet showed positive p53 staining had histologic evidence of malignancy. The third patient died without a postmortem examination. Of the 17 cytologically suspicious cases, 16 (94.1%) were later proven to be malignant, and p53 was positive in 4 (25%). These results suggest that p53 immunostaining could be of value as a marker of malignancy in the cytologic examination of body fluids. The presence of p53 immunoreactivity in cytologic samples is strongly suggestive of malignancy, though its absence does not exclude neoplasia.

A retrospective analysis of 94 patients with CIN and false negative cervical smears taken at colposcopy

This report investigates the reasons for false negative cervical cytology in 94 out of 630 patients (15%) in whom cervical intraepithelial neoplasia (CIN) was diagnosed on colposcopically directed biopsy. Cervical smears were taken immediately before biopsy and the cases with false negative cytology were compared with those whose cytology was abnormal. Patients with false negative cytology were more likely to have been younger (P < 0.01), to have had fewer pregnancies (P < 0.001), to have had a less severe grade of dyskaryosis on their referral smear (P < 0.001), to have had no endocervical cells on the smear (P < 0.05), to have had a less severe grade of CIN on biopsy (P < 0.001), to have had no punctation visible at colposcopy (P < 0.01), and to have had no mosaic pattern seen at colposcopy (P < 0.05). We found no effect attributable to the patient's menstrual history, the interval between referral smear and colposcopy clinic visit, the smear taker or the type of spatula used to take the smear.

Discriminant analysis for classification of murine melanomas and human cervical epithelial cells

Computer analysis of cell images offers many advantages over routine visual examination. It leads to quantitative and accurate detection of subvisual information and provides reproducible measures so that objective decisions in cancer diagnosis become possible. Such diagnostic decisions usually follow partly from a classification process. In this paper two multivariate discriminant analysis methods--namely, linear discriminant analysis (LDA) and quadratic discriminant analysis (QDA)--are presented. LDA and QDA were used to classify cytologic data based on some morphodensitometric measurements. The cytologic data constituted two samples, one representing B16 cell lines and the other including three types of normal human cervical epithelial cells. LDA and QDA were assessed both individually and in comparison to each other, mainly on the basis of the rate of correct classification and robustness. The measurements extracted from the cytologic data employed were shown to be stable and consistent. The statistical results obtained from experiments on cervical cells look particularly promising and encouraging for future work. It has also been shown in this study that the classification techniques employed are valid and that LDA performed almost as well as QDA.

A prospective randomized comparison of fine needle aspiration biopsy and fibreoptic bronchoscopy in the investigation of peripheral pulmonary opacities

Twenty-nine patients, aged 66(+/- 7) years with a peripheral pulmonary opacity (mean diameter 3.6 +/- 1.8 cm) believed to be a tumor, were randomly allocated to initial investigation by either fibreoptic bronchoscopy or percutaneous fine needle aspiration biopsy, the latter performed under fluoroscopic control. The patients proceeded to the alternative investigation in the event of the first failing to achieve a diagnosis. Malignancy was confirmed by the initial procedure in 14/15 patients randomized to fine needle aspiration biopsy but only in 1/14 patients randomized to fibreoptic bronchoscopy (P less than 0.01). Overall, these figures were 25/28 fine needle aspiration biopsy and 2/15 fibreoptic bronchoscopy (P less than 0.01). These results confirm the clinical suspicion that fine needle aspiration biopsy is far more likely than fibreoptic bronchoscopy to establish the presence of malignancy in peripheral pulmonary opacities.

Natural history of the benign breast lump

A prospective study of 112 patients with clinically discrete benign breast lumps has shown that 68 per cent of patients experienced resolution of their lumps over a period of up to 2 years. Resolution of both fibro-adenomas and discrete areas of fibro-adenosis was observed. Diagnosis was achieved by clinical examination and fine needle aspiration cytology. Four patients thought clinically to have benign disease were proven by cytology to have a carcinoma, but no patient with a cytopathological diagnosis of benign disease has developed cancer during or subsequent to this study. We recommend that patients under 35 years of age with clinically and cytologically benign breast lumps can be offered the option of non-excision in the reasonable expectation of resolution of their lesion.

Use of fine needle aspiration cytology with immediate reporting in the diagnosis of breast disease

Fine needle aspiration biopsy for cytological examination (FNAC) is becoming increasingly accepted as a means of tissue diagnosis in breast disease. This study examines the feasibility and accuracy of FNAC in 'immediate reporting' by a consultant cytopathologist in a busy breast clinic. Over a 2-year period, 884 cytology reports were analysed. An initial clinical report and subsequent final cytological diagnosis was made. Fine needle aspiration provided adequate material for cytological evaluation in 635 of the 884 biopsies (71.6 per cent) and this proportion was greater when discrete lumps were considered (463 of 562 biopsies = 82.4 per cent). In diffuse and cystic disease, however, the adequacy of specimens was reduced: 50 per cent and 65 per cent respectively. On immediate reporting the diagnostic sensitivity for all patients was 88 per cent (discrete lumps only, 92.5 per cent) and the specificity was 99.8 per cent (discrete lumps only, 100 per cent). FNAC retains its diagnostic accuracy when immediate reporting is employed and this study demonstrates that this technique can be used in making a diagnosis in patients with breast disease.

Prospective evaluation of fine needle aspiration in the diagnosis of lung cancer

The role of fine needle aspiration biopsy has been assessed prospectively in the diagnosis of discrete lung shadows. A questionnaire was completed before each of 100 biopsies (in 97 patients) to determine the clinician's pretest diagnosis and the likelihood of malignancy. The latter estimates were combined with the previously established sensitivity (71%) and specificity (100%) of the procedure for diagnosing malignancy in the unit to allow calculation in each case of the change in certainty of malignancy as a result of the investigation. Among the 100 biopsies there were 73 true positive and 13 true negative results. There were no false positive results but there were 14 false negatives (cases where malignancy was later proved but where the biopsy did not show unequivocal evidence of malignancy). Among the 27 negative biopsy results the clinician had estimated the likelihood of malignancy as 80% or more in 13 cases. In 11 of these 13 patients the eventual diagnosis proved to be a malignant tumour; on the other hand, six of the 10 patients given a less than 50% chance of malignancy had a benign outcome. A positive biopsy result was therefore quantitively of greatest value when the prior estimate of malignancy was low. In the case of the false negative results the prior probability of malignancy was usually sufficiently high to merit further investigation. It is estimated that the procedure led to the avoidance of thoracotomy in up to 14 of 97 patients.

Fine needle aspiration biopsy in diagnosis of metastases to thyroid gland

Three cases of metastasis to the thyroid gland are reported, in each of which fine needle aspiration biopsy confirmed the diagnosis and obviated the need for surgery. Fine needle aspiration biopsy is able to confirm suspected intrathyroid metastasis and can be performed as an outpatient or bedside procedure.