Liquid-based cytology versus conventional Papanicolaou smear in an organized screening program : a prospective randomized study

Cervical cancer screening efficacy using SurePath, ThinPrep and conventional cytology: A large data set analysis from the Japan Cancer Society

OBJECTIVE

Over the past decade, liquid-based cytology has replaced conventional cytology for cervical cancer screening in many countries, including Japan. We aimed to evaluate the efficacy of liquid-based cytology using a large database and compare two major liquid-based cytology platforms, SurePath and ThinPrep, to conventional cytology.

METHODS

Cervical cancer screening data were collected from the Japan Cancer Society between 2015 and 2019. The efficacy of liquid-based and conventional cytology in detecting cervical intraepithelial neoplasia (CIN) was evaluated. Detection rates and positive predictive values were compared using a Poisson regression model.

RESULTS

We collected data of 3,918,149 participants, including 2,248,202 conventional cytology, 874,807 SurePath and 795,140 ThinPrep smears. The detection rate of CIN2 or more was 1.14 times higher using SurePath than that using conventional cytology (95% confidence interval [CI], 1.09-1.20; p < 0.001). Contrastingly, the detection rate of CIN2 or more was 0.91 times lower using ThinPrep (95% CI, 0.86-0.96; p < 0.001). The detection rates of CIN3 or more did not differ significantly between SurePath and conventional cytology (detection rate ratio, 1.04; 95% CI, 0.97-1.12; p = 0.224). The positive predictive value ratios of CIN2 or more were 0.80 using SurePath (95% CI, 0.76-0.84; p < 0.001) and 0.83 using ThinPrep (95% CI, 0.79-0.87; p < 0.001) compared with conventional cytology.

CONCLUSIONS

Liquid-based cytology, particularly SurePath, was useful for detecting CIN2 or higher in population-based cervical cancer screening. Further widespread use of liquid-based cytology methods would lead to efficient detection of cervical precancerous lesions.

Enhancing cervical cancer cytology screening via artificial intelligence innovation

A double-check process helps prevent errors and ensures quality control. However, it may lead to decreased personal accountability, reduced effort, and declining quality checks. Introducing an artificial intelligence (AI)-based system in such scenarios could effectively address the risk of oversights. This study introduces an innovative AI-integrated workflow for cervical cytology screening that substantially improves efficiency and reduces the burden on cytologists. The AI model prioritizes cases for review based on anomaly scores and streamlines the first screening process to approximately 10 s per case. The model enhances the identification of high-risk cases via detailed microscopic observation, high anomaly scores cases, and a targeted review of low-score cases. The workflow highlights its capability for rapid, accurate, and less labor-intensive evaluations, demonstrating the potential to transform cervical cancer screening. This study highlights the importance of AI in modern medical diagnostics, particularly in areas with a high demand for accuracy and efficiency.

"Modernizing Cervical Cytology Screening with Liquid-Based Methods at Community-Level Hospitals: A Much-Needed Breakthrough for India"

Introduction

Cervical cancer still ranks highest causing cancer-related morbidity and mortality in women in India. It is prudent to emphasise and implement cervical cancer screening strategies in the population efficiently and with regular intervals. Conventionally, PAP smear cytology is obtained by wooden spatula-Ayre's spatula. To improve sensitivity and specificity of the procedure and detection rate, better techniques of cells retrieval are available mainly liquid-based cytology (LBC), with help of cyto-brush. Literature has consistently proven efficiency of the technique and also reduced the proportion of inadequate sampling. We conduct this study to compare both the techniques and efficiency in a community hospital from data over 6 years, to asses its role and benefits among Indian women.

Aims and Objectives

To compare conventional PAP smear and liquid-based cytology techniques analysing detection rates of positive lesions (CIN and also includes ASCUS and malignant), incidence of inadequate sampling, efficiency and cost-effectiveness.

Methods

This is retrospective study at tertiary care obstetric hospital affiliated to government-run medical college in a metropolitan city of Mumbai. Data are retrieved from the Pathology Department, Medical Records Department, laboratory books and OPD registers. Pap's smear sampling was done mainly from OPD with all indications including routine tests as a part of gynaecological evaluation and screening, as well as for suspicious lesions on inspection. Group A consists women who had conventional PAP smear test for 3 years (Dec 2015-Nov 2018) and Group B had women who benefited by LBC method for 3 years (Dec 2018-Nov 2021). COVID-19 pandemic majorly affected the routine gynaecological OPD practice during 2021 as hospital was COVID facility hospital.

Results

Demographic parameters and presentations were comparable and similar. LBC methods have higher detection rate for positive reports, including ASCUS. But results were comparable in both groups and not statistically different. Importantly, incidences of inadequate sampling are reduced significantly with the LBC method. Unsatisfactory smears war high in Group A (7.752%) compared to Group B (3.712%) p-value 0.005, stating the increased rate of requirement of sending repeat smears, which involves higher engagement of time, resources and active participation from healthcare personnel.

Conclusion

Good detection rates and significantly low rates of unsatisfactory smears make LBC rational and cost-effective. These are the times to switch to liquid-based cytology techniques, especially at the community level hospitals; in order to detect more women with cervical premalignant as well as malignant neoplastic lesions and to save lives. This can be made possible by emphasising the policy makers to incorporate these services through quality resources.

Fractal Dimension, Circularity, and Solidity of Cell Clusters in Liquid-Based Endometrial Cytology Are Potentially Useful for Endometrial Cancer Detection and Prognosis Prediction

Endometrial cancer (EC) in women is increasing globally, necessitating improved diagnostic methods and prognosis prediction. While endometrial histology is the conventional approach, liquid-based endometrial cytology may benefit from novel analytical techniques for cell clusters. A clinical study was conducted at the University of Fukui Hospital from 2012 to 2018, involving 210 patients with endometrial cytology. The liquid-based cytology images were analyzed using cell cluster analysis with Image J software. Logistic regression, ROC analysis, and survival analysis were employed to assess the diagnostic accuracy and prognosis between cell cluster analysis and EC/atypical endometrial hyperplasia (AEH). Circularity and fractal dimension demonstrated significant associations with EC and AEH, regardless of age and cytology results. The ROC analysis revealed improved diagnostic accuracy when combining fractal dimension with cytology, particularly in menopausal age groups. Lower circularity and solidity were independently associated with poor overall survival, while higher fractal dimension values correlated with poorer overall survival in Grades 2 and 3 endometrial cancers. The combination of circularity and fractal dimension with cytology improved diagnostic accuracy for both EC and AEH. Moreover, circularity, solidity, and fractal dimension may serve as prognostic indicators for endometrial cancer, contributing to the development of more refined screening and diagnostic strategies.

BD SurePath Direct to Slide (DTS) cervical cytology: Migrating the benefits of liquid-based cytology to low-resource settings

OBJECTIVES

The benefits of liquid-based cytology (LBC) in routine cervical cancer screening are often associated with the availability of instrumented platforms and economic considerations. A low-cost alternative to LBC in low-volume settings remains an unmet need.

METHODS

A multisite evaluation of the BD SurePath (SurePath) LBC Direct to Slide (DTS) method was conducted. The DTS preparations were evaluated across 3 sites. Cytology features for DTS preparation included predetermined thresholds for total cellularity, cell distribution, cellular preservation, and stain quality. Rare event detection was evaluated using SiHa cells spiked into pools from negative cytology specimens. Concordance between Bethesda classification results was evaluated for SurePath LBC and DTS methods using routinely collected SurePath specimens in a split-sample study design.

RESULTS

The DTS specimens met criteria for total cellularity, cell distribution, cellular preservation, and stain quality in more than 98% of all cases. Rare event detection was observed with an average detection of 5 SiHa cells per 2 mL of specimen. Concordant cervical cytology classifications were observed between SurePath LBC and DTS methods.

CONCLUSIONS

The results demonstrate that the DTS process is suitable for routine cervical cytology evaluation. The procedure is reproducible and detected abnormal cervical cells in concordance with standard SurePath LBC preparation.

Analysis of the Differences between Bethesda Groups according to Conventional Smear and Liquid-Based Cytology Methods in Cervicovaginal Cytology: A Single-Center Experience with 165,915 Cases

INTRODUCTION

Liquid-based cytology (LBC) has replaced conventional smear (CS) in the world. In this study, through a series with a large number of cases, we aimed to make a comparison and general evaluation in all groups, primarily epithelial abnormalities, according to LBC and CS methods. This study was carried out in a private pathology laboratory located in a metropolitan city, where cytological materials sent from many clinics were examined.

MATERIAL AND METHODS

There were 165,915 cases whose smears were examined between 2012 and 2020, most of them conventional (131,224 CS, 34,691 LBC). Cases were evaluated on the basis of the Bethesda 2014 classification and divided into sub-diagnostic categories after they were divided into two main groups as "with epithelial abnormalities" and "without." χ2 and Fischer's precision statistical tests were conducted using SPSS 23.0 package. In the CS process, cervical samples were obtained using an endocervical brush and a spatula. Cells were directly spread onto the slides and promptly fixed in 95% ethanol, followed by staining with the standard Papanicolaou stain. For LBC ThinPrep, cervical specimens were gathered using a cervix brush. The brush was washed in a vial and discarded. Finally, cells were isolated through vacuum filtration and transferred to the slide using air pressure.

RESULTS

Squamous cell abnormalities (atypical squamous cells of undetermined significance [ASC-US], atypical squamous cells - cannot exclude high-grade squamous intraepithelial lesion [ASC-H], low-grade squamous intraepithelial lesion [LSIL], high-grade squamous intraepithelial lesion [HSIL], squamous cell carcinoma, atypical glandular cells of undetermined significance) were reported in 5,696 (3.43%) cases. ASC (ASC-US + ASC-H)/SIL ratio (1.36/2.04) was found to be 0.67 (recommended Bethesda ratio is <3). ASC-US (p < 0.001), ASC-H (p < 0.001), and HSIL(p < 0.001) detection rate of LBC was found to be significantly higher than CS. ASC-US (1.8/1.2), ASC-H (0.08/0.008), and HSIL (0.6/0.3) case ratios of LBC/CS were found to be significantly higher in LBC. LSIL (1.72/1.66) rate was similar.

CONCLUSION

LBC is superior to CS in detecting epithelial lesions. In addition to being used as a screening method, it is clear that it makes a great contribution to reducing cervical carcinomas due to HPV typing. Definitive comments regarding comparison of methods on reactive changes and microorganism detection are challenging. Preanalytical factors might account for these situations.

Comparative Analysis of Conventional Cytology and Liquid-Based Cytology in the Detection of Carcinoma Cervix and its Precursor Lesions

Context

The conventional smears (CS) and Liquid based cytology (LBC) are important tools to detect carcinoma cervix and its precursor lesions.

Aims

The present study was done to compare the cytomorphological features of cervical lesions using both techniques and compare with the histopathological diagnosis.

Settings and Design

This was a prospective observational study over a period of 1.5 years at a tertiary care hospital.

Methods and Material

A total of 969 women in the age group of 21-65 years presenting with either routine screening or complaints of vaginal bleeding, discharge, or pelvic pain were enrolled for the study. Both the CS and LBC smears were analyzed and compared with the corresponding histopathology diagnosis. The data was analyzed using Statistical Package for the Social Sciences (SPSS) software and P values <0.05 were considered significant.

Results

There were 8.57% unsatisfactory smears in CS as compared to 0.5% in LBC smears. Liquid-based cytology was superior to conventional preparations in terms of smear adequacy, lesser hemorrhagic and inflammatory background, and presence of more endocervical cells. Liquid-based cytology showed a better yield in detecting all the types of epithelial cell lesions with a concordance rate of 73.9% between the two techniques. On histopathology correlation of these lesions, LBC had a higher sensitivity (96.67%) and diagnostic accuracy (99.08%) as compared to CS (73.33% and 92.66%, respectively).

Conclusions

Liquid-based cytology is superior to conventional cytology for the detection of epithelial cell lesions. Reduction in the unsatisfactory smears, a cleaner background, and better representation of the sample are more significantly appreciated on LBC in contrast to CS.

A Comparison of Conventional Pap Smear and Liquid-Based Cytology for Cervical Cancer Screening

Objectives

Early diagnosis and treatment of preinvasive lesions have made cervical cytology one of the most effective methods of cancer screening in industrialized nations, which have seen a sharp decline in the incidence and death of invasive cancer. The aim of this study is to compare liquid-based cytology (LBC) and conventional Pap on cervical smears.

Materials and Methods

From July 2018 to June 2022, 600 patients were included in this cross-sectional study, which was done at the Pathology Department of a Tertiary Care Facility in Western Maharashtra.

Results

Of the 600 patients, 570 (95%) had good conventional Pap smear (CPS), whereas 30 (5%) had poor ones. Five hundred and ninety-two (98.6%) LBC smears were satisfactory, whereas 8 (1.4%) were unsatisfactory. Endocervical cells were seen in 294 (49%) CPS, whereas 360 (60%) LBC smears showed endocervical cells. The morphology of inflammatory cells was similar in both techniques. Hemorrhagic background was seen in 212 (35%) CPS and 76 (12.6%) LBC smears. Only two samples showed diathetic background, which was seen on both CPS and smear. Out of the satisfactory smears in the case of CPS, 512 (85%) cases were reported as negative for intraepithelial lesion or malignancy (NILM), whereas 58 (9.7%) cases were reported as epithelial cell abnormality. In LBC smears, 526 (87.3%) were reported as NILM, whereas 66 (11%) were reported as epithelial cell abnormality. Organisms were detected in 208 (34%) CPS and 162 (27%) LBC smears. Screening time was 5 ± 1 min for CPS, whereas it was 3 ± 1 min for LBC smear.

Conclusion

Mortality will be decreased using LBC on a bigger scale in nations where many smears can be made and screened in a short amount of time, with the provision of doing human papillomavirus-based testing on the remaining sample.

Should screening for cervical cancer go to primary human papillomavirus testing and eliminate cytology?

This review will systematically highlight the pros and cons of cervical cancer screening with HPV (human papillomavirus) testing and cytological methods (Papanicolaou (Pap) test). When comparing the screening modalities, various facets will be addressed, such as cost effectiveness, and harms and benefits across different demographics and age groups. It is important to note that due to the expansive variance in material costs, practices, and resource availability across different geographical regions, these comparisons are far from straight forward, and ultimately make it challenging to render definitive global recommendations. Thus, the intent of this review is to highlight some of the differences in difference cervical cancer screening modalities that can help one to choose an optimal screening method in their specific situation.

Efficacy of careHPV™ human papillomavirus screening versus conventional cytology tests for the detection of precancerous and cancerous cervical lesions among women living with HIV-1 in Lao People's Democratic Republic

BACKGROUND

In the Lao People's Democratic Republic (Lao PDR), cervical cancer is the third leading cause of women cancer.

AIMS

The objective of this cross-sectional study was to compare the efficacy of careHPV™ test versus conventional Pap smear or Siriraj liquid-based cytology in the detection of cervical cancer in women living with human immunodeficiency virus type 1 (HIV-1).

MATERIALS & METHODS

Overall, 631 women consented to participate. Four cervical specimens were taken for the purpose of conventional Pap smear, Siriraj liquid-based cytology, careHPV™ test, and HPV-16 genotyping. The exact McNemar test was used to compare the efficacy and diagnostic performance of the tests.

RESULTS

Of the 631 women with follow-up, 331 were human papillomavirus (HPV) negative. High-grade squamous intraepithelial lesions were found in 37 women, biopsy-proven high-grade cervical intraepithelial neoplasia in 50 women, and invasive carcinoma in seven women. The proportion of women with high-grade cervical lesion or carcinoma detected after abnormal careHPV™ test was higher (6.02%; 95% confidence interval [CI]: 4.4-8.1) than that detected by conventional Pap smear (4.59%; 95% CI: 3.2-6.5). careHPV™ and HPV-16 genotyping had, respectively, the highest sensitivity (80.8%; 95% CI: 67.4-89.5) and specificity (92.2%; 95% CI: 89.8-94.2). HPV-16 was the most frequently detected genotype.

CONCLUSIONS

careHPV™ test represents a screening option in Lao PDR, particularly in women living with HIV-1 because of higher prevalence of chronic HPV in this population.

The reporting rates of high-grade squamous intraepithelial lesions and their human papillomavirus testing and histologic follow-up results: A comparison between ThinPrep and SurePath preparations

BACKGROUND

Liquid-based cytology (LBC) tests SurePath (SP) and ThinPrep (TP) have largely replaced conventional Papanicolaou (Pap) tests for cervical cytology screening due to higher sensitivity. However, comparison between SP and TP test sensitivity and efficacy in detecting squamous abnormalities is lacking. Our study aims to compare high-grade squamous intraepithelial lesion (HSIL) reporting rates, human papillomavirus (HPV) positivity rates, and histologic outcome between these two LBC methods.

MATERIALS AND METHODS

We performed a retrospective search of the period between January 2014 and June 2017, when both TP and SP were utilized at our institution, to identify HSIL cases and collect the HPV testing and histologic follow-up results for those cases.

RESULTS

One hundred twenty-five HSILs were identified from the 15 382 TP specimens (0.81%) and 93 HSILs were identified from the 25 105 SP specimens (0.37%), a statistically significant difference (P < .0001). The corresponding HPV positivity rates were 95.6% and 89.7% in TP-HSILs and SP-HSILs, respectively, a statistically non-significant difference. Histologic follow-up showed HSILs or carcinomas were identified in 78% (49/63) of TP-HSILs and 79% (45/57) of SP-HSILs, with no statistically significant difference.

CONCLUSION

TP demonstrated a higher HSIL detection rate than SP with no significant difference in follow-up HPV or histologic results.

High-risk human papillomavirus test in anal smears: can it optimize the screening for anal cancer?

OBJECTIVE

The current method for screening anal cancer is anal cytology, which has low sensitivity. Since high-risk human papillomavirus (HR-HPV) is associated with almost 90% of cases of anal cancer, the objective of this study is to evaluate whether testing for HR-HPV can optimize the screening.

DESIGN

Prospective study with patients enrolled in a screening program for anal dysplasia. Considering high-resolution anoscopy (HRA)-guided biopsy as the gold standard for diagnosis of high-grade squamous intraepithelial lesions, the diagnostic performance of anal cytology, HR-HPV testing, and the combination of both was calculated.

SETTINGS

A single center for anal dysplasia.

PARTICIPANTS

A total of 364 patients (72% males, 82% HIV-positive).

INTERVENTION

Patients underwent anal cytology, HR-HPV test, and HRA-guided biopsy of the anal canal.

MAIN OUTCOME MEASURES

Ability of cytology and HR-HPV test (individually and combined) to detect high-grade squamous intraepithelial lesions, and analysis of the cost of each diagnostic algorithm.

RESULTS

Cytology alone was the cheapest approach, but had the lowest sensitivity [59%, 95% confidence interval (CI) 46-71%], despite of highest specificity (73%, 95% CI 68-78%). Cotesting had the highest sensitivity (85%, 95% CI 74-93%) and lowest specificity (43%, 95% CI 38-49%), and did not seem to be cost-effective. However, HR-HPV testing can be used to triage patients with normal and atypical squamous cells of undetermined significance cytology for HRA, resulting in an algorithm with high sensitivity (80%, 95% CI 68-89%), and specificity (71%, 95% CI 65-76%), allied to a good cost-effectiveness.

CONCLUSION

HR-HPV testing is helpful to optimize the screening in cases of normal and atypical squamous cells of undetermined significance cytology.

The first-round results of a population-based cohort study of HPV testing in Japanese cervical cancer screening: baseline characteristics, screening results, and referral rate

Objective

In 2013, a cohort study aimed to clarify the positive and negative effects of introducing the human papillomavirus (HPV) testing for population-based cervical cancer screening has been launched in Japan. This study included four screenings during the subsequent 7-year follow-up period. We aim to describe the results of the first round of this study on cervical cancer screening here.

Methods

This study began in September 2013 with recruitment completed in March 2016. Women aged 30–49 years were divided into 2 groups: those who received uterine cervical cytology alone in the first year (control group), or those who received a combination of cytology and HPV testing (intervention group), based on their age. After first screening, women with positive result of cytology or positive HPV test required referral. We summarized the results of the first round of cervical cancer screening.

Results

Of the 25,074 women who were eligible for the study, 13,845 women (55.2%) were screened with cytology alone; 11,229 women (44.8%) received a combination of cytology and HPV testing. After screening, 407 women (2.9%) in the control group and 1,003 women (8.9%) in the intervention group required referral, respectively. Adding HPV testing increased referral rate significantly (p<0.001).

Conclusion

After first screening, introduction of HPV testing appears to contribute to significantly higher referral rates, suggesting that the number of colposcopies as a detailed examination may increase. These preliminary findings suggest that if HPV testing is introduced into screening, medical institutions need to be prepared for an increasing number of follow-up examinations.

A comparison of liquid-based and conventional cytology using data for cervical cancer screening from the Japan Cancer Society

OBJECTIVE

Liquid-based cytology has replaced conventional cytology in cervical cancer screening in many countries. However, a detailed comparison of liquid-based cytology with conventional cytology has not been reported in Japan. Therefore, the aim of the study is to evaluate efficacy of liquid-based cytology in Japan.

METHODS

We first evaluated the prevalence of use of liquid-based cytology and then examined the efficacy of liquid-based cytology and conventional cytology for detecting CIN and the rate of unsatisfactory specimens using data from cancer screening collected by the Japanese Cancer Society from FY2011 to FY2014. A Poisson regression model with random effects analyses was used to classify histological outcomes and unsatisfactory specimens using liquid-based cytology compared to conventional cytology.

RESULTS

A total of 3 815 131 women were analyzed in the study. The rate of liquid-based cytology increased from approximately 8% in FY2011 to 37% in FY2014. Compared to conventional cytology, the detection rates with liquid-based cytology were significantly higher (1.42 times) for CIN1+ [detection rate ratio (DRR) = 1.42, 95% confidence interval (CI) 1.35-1.48, P < 0.001] and CIN2+ (DRR = 1.16, 95% CI 1.08-1.25, P < 0.001). Positive predictive value ratios of CIN1+ and CIN2+ were also significantly higher for liquid-based cytology than for conventional cytology. However, there was no significant difference between liquid-based cytology and conventional cytology for detection rates and positive predictive values of CIN3+ and cancer. The rate of unsatisfactory specimens was significantly lower with liquid-based cytology compared to conventional cytology (DRR = 0.07, 95% CI 0.05-0.09, P < 0.001).

CONCLUSIONS

In order to avoid the unsatisfactory specimens in cervical cancer screening, the results of this study did indicate that liquid-based cytology was more useful than conventional cytology in practical standpoints.

CIN III and cervical SCC with negative oncogenic HPV PCR: A case series

With the recent introduction of the renewed National Cervical Screening Program (NCSP) in Australia, utilising primary human papillomavirus (HPV) nucleic acid testing (NAT) for known oncogenic HPV types rather than cervical cytology, we reflect on three asymptomatic women with negative oncogenic HPV test results and high-grade cervical abnormalities including cervical intraepithelial neoplasia (CIN) III and cervical squamous cell carcinoma (SCC). The two cases with CIN III had a 'probable' oncogenic subtype (HPV 53) identified on further testing, while the case of SCC had no HPV virus identified. These cases serve as a reminder of the need for ongoing diligence despite low-risk screening under the new program.

Characterizing the Effect of Automated Cell Sorting Solutions on Cytomorphological Changes

INTRODUCTION

Liquid-based cytology has become a widely adopted, automated screening system for gynecologic and nongynecologic cytology. Automated screening systems function by distinguishing atypical cells based on their cytoplasmic and nuclear areas, densitometric measurement, and so on. However, the morphological influence of the washing solution has not been fully considered. Here, we examined the morphological effect and temporal change resulting from saving the cytologic samples in various solutions.

METHODS

Cytologic specimens were obtained from the ascites (AS) of patients with peritoneal cancer. Various solutions of a physiological saline, a Ringer's solution, a low-molecular dextran L injection, VOLUVEN 6% solution, MIXID L injection (ML), RPMI-1640 medium, and horse serum (HS) were added to aliquot sediments. All samples were refrigerated at 4°C, and aliquots were subsequently processed at specific time points (0, 1, 2, 4, 7, and 14 days). For all samples, cytoplasmic and nuclear size of the Papanicolaou-stained specimens were measured.

RESULTS

In terms of cytoplasmic and nuclear areas, samples stored in ML and HS showed no significant difference compared to the AS sample; in contrast, the other samples were significantly larger in both cytoplasmic and nuclear areas than the AS sample. In examining the temporal change among the solutions, we found that the cytoplasms and nuclei became small over the time course for all of the tested solutions.

CONCLUSION

We showed that cells swell in the solution after 1 h of storage and contract as time progresses. Together, our findings have important implications for how mathematical analysis is applied during the automated screening process.

Histopathological Patterns and Characteristics of Abnormal Cervical Smear in Madinah Region of Saudi Arabia

Cervical cancer is a major public health problem that continues to be one of the leading female genital cancers worldwide. In the kingdom of Saudi Arabia (KSA), cervical cancer ranks the fifteenth most frequent cancer among females. This study is the first published research study addressing the screening of cervical cancer in Madinah region of KSA.

Can LBC Completely Replace Conventional Pap Smear in Developing Countries

Background

A number of screening techniques have been developed to reduce the incidence of cervical cancer, most common of which is conventional Pap smear (CPS) being overtaken by liquid-based cytology (LBC) in most of the developed countries. There are a number of studies with conflicting results, and no method has been shown superior in terms of all parameters. LBC was introduced in our hospital in 2014, and we planned to do a study and compare results of the two techniques. This study aims to compare the two methods in terms of sensitivity, specificity, positive predictive value and negative predictive value, turnover time, cost-effectiveness, sample adequacy. This study has been done in 100 women with unhealthy cervix to increase the output.

Method

This was a prospective observational study. A total of 100 women fulfilling the inclusion criteria were subjected to screening test. In first 50 cases, first conventional Pap smear was taken and then LBC, and in remaining 50 cases, first LBC and then conventional Pap smear were taken; this was done to remove bias.

Results

The number of unsatisfactory slides was reduced with LBC, and turnover time was less for LBC. The detection of ASCUS was increased with LBC, but the detection of higher-grade lesions (HSIL and SCC) was equal with both tests.

Conclusion

The superiority of LBC with respect to reduction in the number of unsatisfactory slides and less turnover time is being offset with increased detection of low-grade lesions subjecting women to further testing increasing the cost of programme and anxiety among women. It is difficult to say that it can completely replace conventional Pap smear in low-resource settings.

Prevention of Cervical Cancer: Guideline of the DGGG and the DKG (S3 Level, AWMF Register Number 015/027OL, December 2017) - Part 1 with Introduction, Screening and the Pathology of Cervical Dysplasia

Aims Annual opportunistic screening for cervical carcinoma has been carried out in Germany since 1971. The creation of this S3 guideline meets an important need, outlined in the National Cancer Plan, with regard to screening for cervical cancer, as the guideline aims to provide important information and support for planned organized screening for cervical cancer in Germany. Methods With the financial support of German Cancer Aid, 21 professional societies developed evidence-based statements and recommendations (classified using the GRADE system) for the screening, management and treatment of precancerous conditions of the cervix. Two independent scientific institutes compiled systematic reviews for this guideline. Recommendations The first part of this short summary presents the pathological basis and considers various questions related to screening for cervical cancer. As also reported in earlier reviews, the meta-analysis by Kleijnen Systematic Reviews showed that HPV-based screening offers better protection against invasive cervical cancer compared to cytology-based screening. The authors of this guideline therefore recommend - in accordance with the guideline of the Joint National Committee of Germany (Gemeinsamer Bundesauschuss, G-BA) - that women aged 35 and above should be examined at regular intervals (at least every 3 years) and undergo HPV-based screening. Co-testing can also be carried out. Women between the ages of 20 and 35 should have cytological screening every 2 years.

Cervical Cancer Screening Programs in Europe: The Transition Towards HPV Vaccination and Population-Based HPV Testing

Cervical cancer is the fourth most frequently occurring cancer in women around the world and can affect them during their reproductive years. Since the development of the Papanicolaou (Pap) test, screening has been essential in identifying cervical cancer at a treatable stage. With the identification of the human papillomavirus (HPV) as the causative agent of essentially all cervical cancer cases, HPV molecular screening tests and HPV vaccines for primary prevention against the virus have been developed. Accordingly, comparative studies were designed to assess the performance of cervical cancer screening methods in order to devise the best screening strategy possible. This review critically assesses the current cervical cancer screening methods as well as the implementation of HPV vaccination in Europe. The most recent European Guidelines and recommendations for organized population-based programs with HPV testing as the primary screening method are also presented. Lastly, the current landscape of cervical cancer screening programs is assessed for both European Union member states and some associated countries, in regard to the transition towards population-based screening programs with primary HPV testing.

Comparison of conventional Pap smear and liquid-based cytology: A study of cervical cancer screening at a tertiary care center in Bihar

Background

Cervical cancer is the fourth leading cause of cancer in women in the world and it is the second most common cancer in women 15-44 years of age. Strict implementation of screening programs has led to a large decrease in cervical cancer incidence and mortality in the developed countries. In contrast, cervical cancer remains largely uncontrolled in high-risk developing countries because of ineffective or no screening programs. Conventional Pap smear method has been the mainstay of most of the screening programs for many decades. However, this technique is not without limitations, and the sensitivity and specificity of cervical cytology are relatively low. To overcome the limitations of conventional Pap smear (CPS), liquid-based cytology (LBC) was introduced in 1990s as a better tool for processing cervical samples.

Objectives

This study was undertaken to compare CPS with liquid-based methods, to assess the effectiveness and feasibility of LBC over CPS in our setting, and also to evaluate the prevalence of human papillomavirus (HPV) in our population.

Materials and Methods

This study was conducted in Gynecological Oncology Unit of Regional Cancer Center at Indira Gandhi Institute of Medical Sciences, Patna, Bihar. About 310 women were enrolled in this study and the sample was taken for both conventional cytology and LBC. The smears were studied in detail and were interpreted as per the Bethesda system of reporting Pap smears. The results were compared and analyzed statistically.

Results

Unsatisfactory smears were more commonly reported by conventional method (7.1%) than with liquid-based method (1.61%), and this difference is statistically significant. There was no difference in the detection of epithelial cell abnormalities using both the methods. HPV DNA for high-risk oncogenic strains (16 and 18) was detected in 6.45% of women in this study.

Conclusion

LBC has been found to be more superior to conventional smears only with respect to lesser number of unsatisfactory smears, but considering the economic implications of LBC, conventional Pap is more feasible in our setting.

Randomised study shows that repeated self-sampling and HPV test has more than two-fold higher detection rate of women with CIN2+ histology than Pap smear cytology

This corrects the article DOI: 10.1038/bjc.2017.85.

Stability, integrity, and recovery rate of cellular nucleic acids preserved in a new liquid-based cytology medium

BACKGROUND

Liquid-based cytology (LBC) has replaced the conventional Papanicolaou test in cervical cancer screening. The cervical swab specimens collected in LBC media can also be used for additional analyses including high-risk HPV (HR-HPV) test, DNA methylation analysis, and HPV E6/E7 mRNA test.

METHODS

The stability, integrity, and recovery rate of cellular DNA and RNA after storage at different conditions were evaluated by a quantitative real-time PCR (qPCR) based HR-HPV test, reverse transcription qPCR (RT-qPCR), and agarose gel electrophoresis. Cervical swab specimens collected in a newly developed LBC medium, VersaMedium, and ThinPrep PreservCyt medium were processed on Hologic ThinPrep 5000 instrument.

RESULTS

Cervical exfoliative cells fixed by VersaMedium exhibited good cellular morphology with intact membranes and delineated chromatin structures. Cellular DNA preserved in VersaMedium exhibited high level of stability at both room temperature and 4°C, and remained mostly intact at 4°C for up to 28 days. Cellular RNA preserved in VersaMedium maintained higher level of stability and integrity at 4°C than at room temperature. VersaMedium also showed no apparent adverse effect on the recovery rate of nucleic acids.

CONCLUSION

In addition to maintaining cellular morphology, when stored at 4°C, VersaMedium preserves cellular nucleic acids and PreservCyt medium without noticeable adverse effects on the recovery rate during purification. Therefore, VersaMedium is an appropriate LBC medium for the collection and preservation of cervical swab specimens. And VersaMedium preserved cellular nucleic acids are of such high quality that they are suitable for HR-HPV qPCR test and RT-qPCR analyses.

Comparison of Unsatisfactory Samples from Conventional Smear versus Liquid-Based Cytology in Uterine Cervical Cancer Screening Test

BACKGROUND

Cervical cytology for uterine cervical cancer screening has transitioned from conventional smear (CS) to liquid-based cytology (LBC), which has many advantages. The aim of this study was to compare the proportion of unsatisfactory specimens from CS versus LBC at multiple institutions including general hospitals and commercial laboratories.

METHODS

Each participating institution provided a minimum of 500 Papanicolaou (Pap) test results for analysis. Pap tests were classified according to the participating institution (commercial laboratory or general hospital) and the processing method (CS, ThinPrep, SurePath, or CellPrep). The causes of unsatisfactory results were classified as technical problems, scant cellularity, or complete obscuring factors.

RESULTS

A total of 38,956 Pap test results from eight general hospitals and three commercial laboratories were analyzed. The mean unsatisfactory rate of LBC was significantly lower than that of CS (1.26% and 3.31%, p = .018). In the LBC method, samples from general hospitals had lower unsatisfactory rates than those from commercial laboratories (0.65% vs 2.89%, p = .006). The reasons for unsatisfactory results were heterogeneous in CS. On the other hand, 66.2% of unsatisfactory results in LBC were due to the scant cellularity.

CONCLUSIONS

Unsatisfactory rate of cervical cancer screening test results varies according to the institution and the processing method. LBC has a significantly lower unsatisfactory rate than CS.

Comparison of Unsatisfactory Samples from Conventional Smear versus Liquid-Based Cytology in Uterine Cervical Cancer Screening Test

BACKGROUND

Cervical cytology for uterine cervical cancer screening has transitioned from conventional smear (CS) to liquid-based cytology (LBC), which has many advantages. The aim of this study was to compare the proportion of unsatisfactory specimens from CS versus LBC at multiple institutions including general hospitals and commercial laboratories.

METHODS

Each participating institution provided a minimum of 500 Papanicolaou (Pap) test results for analysis. Pap tests were classified according to the participating institution (commercial laboratory or general hospital) and the processing method (CS, ThinPrep, SurePath, or CellPrep). The causes of unsatisfactory results were classified as technical problems, scant cellularity, or complete obscuring factors.

RESULTS

A total of 38,956 Pap test results from eight general hospitals and three commercial laboratories were analyzed. The mean unsatisfactory rate of LBC was significantly lower than that of CS (1.26% and 3.31%, p = .018). In the LBC method, samples from general hospitals had lower unsatisfactory rates than those from commercial laboratories (0.65% vs 2.89%, p = .006). The reasons for unsatisfactory results were heterogeneous in CS. On the other hand, 66.2% of unsatisfactory results in LBC were due to the scant cellularity.

CONCLUSIONS

Unsatisfactory rate of cervical cancer screening test results varies according to the institution and the processing method. LBC has a significantly lower unsatisfactory rate than CS.

Evaluation of microRNA-205 expression as a potential triage marker for patients with low-grade squamous intraepithelial lesions

High-risk human papillomavirus (HPV) testing is a recommended triage approach for females with atypical squamous cells of undetermined significance (ASCUS), but due to its poor specificity this approach is not recommended for patients with low-grade squamous intraepithelial lesions (LSIL). The objective of the current study was to determine microRNA (miR)-205 expression levels in liquid-based cytology (LBC) samples, and evaluate their ability to predict cervical intraepithelial neoplasia grade 2/3 or worse (CIN2/3+) in females with minor cytological abnormalities. LBC samples were obtained from patients attending the Swedish Cervical Cancer Screening Program. The Mann-Whitney U test, one-way analysis of variance, Kruskal-Wallis test, Spearman rank order correlation analysis, and Pearson's χ² test were used to assess the results. Accuracy analyses indicated that high miR-205 expression had a significantly higher specificity to high-risk HPV testing, and a sensitivity similar to that of high-risk HPV testing to predict CIN2+ and CIN3+ in women with LSIL, but not those with high-grade squamous intraepithelial lesions. Although further research is required for females with LSIL, miR-205 expression in LBC samples may be a novel triage marker for, or a beneficial supplement to high-risk-HPV testing in these patients.

A comparison of liquid-based cytology with conventional Papanicolaou smears in cervical dysplasia diagnosis

Background:

Due to the high number of women affected by cervical cancer and the importance of an early diagnosis, combined with the frequent incidence of false-negative Papanicolaou (Pap) smear screening results for this disease, several studies have been conducted in recent years in order to find better tests. Liquid-based cytology (LBC) tests, including the liquid-based thin layer method, have demonstrated the highest potential for reducing false-negative cases and improved sample quality. This study aimed to compare the strength of the Pap smear test with fluid cytology and conventional tests in detecting cervical dysplasia.

Materials and Methods:

This descriptive-analytic study was conducted on 366 women who attended private laboratories for a Pap smear. The Pap smear sampling was conducted simultaneously using two methods: conventional Pap (CP) smear and LBC), from the cervix.

Results:

The mean age of the participants was 32 ± 8.8 years. Diagnostic results of endocervical cells, epithelial cells, vaginitis cells, and metaplastia were consistent with both conventional and liquid cytology smears, and the kappa coefficient was determined to be significant (P < 0.001). In total, 40.5% of diagnostic cases indicated bacterial inflammation 80.3% of the diagnoses in both methods were P1 and 3.9% of cases diagnosed were P2, the overall diagnostic consistency was 83.9% between the two sampling methods. The inflammation diagnosis was 40.5% and this was consistent in both methods of LBC and CP. There was one case of a false-negative diagnosis in the LBC method and 14 cases in the CP method.

Conclusion:

Results showed that the LBC may improve the sample's quality and reduce the number of unsatisfactory cases more than with the CP method.

A comparative analysis of conventional and SurePath liquid-based cervicovaginal cytology: A study of 140 cases

Background:

The role of Papanicolaou (Pap) test in cervical cancer screening need not be overemphasized. While most Western countries have adopted the liquid-based cytology (LBC), which is considered superior, many developing countries are still using the conventional Pap smear (CPS) technique.

Objective:

To compare the staining and cytomorphological features on conventional versus liquid-based cervicovaginal smears.

Materials and Methods:

One hundred and forty cervicovaginal smears prepared by the standard conventional and LBC techniques were interpreted as per the Bethesda system of reporting cervicovaginal smears. Twelve parameters were studied, compared, and statistically analyzed. A P value <0.05 was considered to be statistically significant.

Results:

129/140 (92%) of CPSs and 130/140 (93%) LBC smears were satisfactory. LBC had a significantly shorter screening time (2.0 ± 0.08 vs 4.0 ± 0.65) and better representative material than that of CPS (50% vs 42%). Neutrophils were significantly more in CPS than LBC (96% vs 92%) with a P value <0.05 while hemorrhagic background and red blood cells (RBCs) were more prominent in CPS. LBC showed significant artifactual changes in squamous epithelial cells. Epithelial abnormalities ranging from atypical squamous cells of undetermined significance (ASCUS) to high grade squamous intraepithelial lesion (HSIL) were seen in 3% (4) and 2% (2) of CPSs and LBCs, respectively. Organisms were better picked up in CPS (99% in CPS vs 73% LBC) with a value of P = 0.0001.

Conclusion:

Although a shorter screening time and cleaner background are the major advantages of LBC, CPS is not inferior to LBC. Considering the high cost, rather than the advantages associated with LBC, we feel that CPS is a better option for developing countries.

The advantages of incorporating liquid-based cytology (TACAS™) in mass screening for cervical cancer

We incorporated liquid-based cytology (LBC) in population-based screening for cervical cancer. The usefulness of using LBC in mass screening for cervical cancer was examined. From 2009 to 2014, 157,061 individuals underwent mass screening for cervical cancer in Aomori Prefecture. From 2009 to 2011, cells were collected from 82,218 individuals and the specimens were conventionally prepared (CP). From 2012 to 2014, cells were collected from 74,843 individuals and the specimens were prepared using LBC (TACAS™). Cytology results for the 2 sets of specimens were compared and differences in cytologic features were examined. ASC-US and more severe lesions were detected at a rate of 1.13 % by CP and 1.44 % by LBC, so LBC had a 1.3-fold higher rate of detection. LBC had a 1.6-fold higher rate of LSIL detection and a 1.2-fold higher rate of HSIL detection. CP detected cancer in 20 cases at a rate of 0.024 % while LBC detected cancer in 18 cases at a rate of 0.024 %. Cytodiagnosis of the 18 cases of SCC that LBC identified revealed that 7 were SCC, 8 were HSIL, and 3 were ASC-H. Atypical cells tended to be smaller with TACAS™. LBC reduced the time needed for microscopic examination of a single specimen by 42 % in comparison to CP. LBC using TACAS™ allowed the detection of slight lesions and slight changes in cells. LBC can lessen the burden on medical personnel and may lead to improved accuracy.

Cervical histology after routine ThinPrep or SurePath liquid-based cytology and computer-assisted reading in Denmark

Background:

We compared the sensitivity and specificity of liquid-based cytology (LBC) and computer-assisted reading for SurePath/FocalPoint and ThinPrep with those of manually read conventional cytology in routine cervical screening in four Danish laboratories.

Methods:

Using data from five nationwide registers, technological phases were identified by slide preparation, reading technique, and triage of borderline cytology. Trends in the detection of cervical intraepithelial neoplasia (CIN) were an indicator of the technology's relative sensitivity, and trends in false-positive tests an indicator of relative specificity.

Results:

At 23–29 years, SurePath/FocalPoint statistically significantly increased the detection of ⩾CIN3 by 85% compared with manually read conventional cytology. The 11% increase with ThinPrep was not significant. At 30–44 years, the increase with SurePath/FocalPoint was 58% the 16% increase with ThinPrep was not significant. At 45–59 years, both technologies led to nonsignificant decreases in the detection. SurePath/FocalPoint doubled the frequency of false-positive tests at any age. With ThinPrep, these proportions remained the same at 23–29 years, but decreased by two-thirds at 45–59 years. In a fourth laboratory with continuous use of manually read conventional cytology, no such trends were seen.

Conclusions:

The sensitivity and specificity of modern LBC and computer-assisted reading technologies may be brand- and age-dependent.

Cervical cancer screening and follow-up in 4 geographically diverse US health care systems, 1998 through 2007

BACKGROUND

Cervical cancer screening and follow-up guidelines have changed considerably in recent years, but to the authors' knowledge few published reports exist to estimate the impact of these changes in community-based settings. The authors examined the patterns and results of cervical cancer testing and follow-up over a decade in 4 geographically diverse US health care systems to inform the future evaluation of changes resulting from increased uptake of the human papillomavirus (HPV) vaccination.

METHODS

The authors studied women aged 21 to 65 years who were members of one of these health systems at any time between 1998 and 2007. Data were collected and standardized across sites, based on receipt of Papanicolaou (Pap) and HPV tests, HPV vaccination, cervical biopsies, and treatment of cervical dysplasia. Annual rates (per 1000 person-years) of Pap testing, HPV testing, and cervical biopsy and treatment procedures were calculated. Screening intervals and trends in the results of screening Pap tests and cervical biopsies also were examined.

RESULTS

Pap testing rates decreased (from 483 per 1000 person-years in 2000 to 412 per 1000 person-years in 2007) and HPV testing rates increased over the study period. Screening frequency varied across health care systems, and many women continued to receive annual testing. All 4 sites moved to less frequent screening over the study period without marked changes in the overall use of cervical biopsy or treatment.

CONCLUSIONS

Despite differences over time and across health plans in rates of cervical cancer testing and follow-up cervical procedures, the authors found no notable differences in Pap test results, diagnostic or treatment procedure rates, or pathological outcomes. This finding suggests that the longer screening intervals did not lead to more procedures or more cancer diagnoses.

Can Genomic Amplification of Human Telomerase Gene and C-MYC in Liquid-Based Cytological Specimens Be Used as a Method for Opportunistic Cervical Cancer Screening?

OBJECTIVE

To evaluate the effectiveness of five methods including the ThinPrep cytological test (TCT), liquid-based cytology, the human papillomavirus (HPV) test, detection of the TERC and C-MYC genes and visual inspection with acetic acid/Lugol's iodine (VIA/VILI) for opportunistic cervical cancer screening, and to explore whether genomic amplification of the human telomerase gene and C-MYC in liquid-based cytological specimens can be used as a method for opportunistic cervical cancer screening.

METHODS

Data were collected prospectively from 1,010 consecutive patients who visited the gynecology clinic and agreed to participate in opportunistic cervical cancer screening at our institution from November 2010 to July 2011. The five methods mentioned above were used for the screening in all cases. The histopathological diagnosis served as the gold standard for the evaluation. A comparison between the five screening methods for the diagnosis of high-grade cervical intraepithelial neoplasia (CIN II and III) was performed for their sensitivity, specificity, false-positive rate, false-negative rate, accuracy rate, positive likelihood ratio and negative likelihood ratio. A comprehensive comparison of the different combination programs for screening was performed according to the analysis of the receiver operating characteristic (ROC) curve area. The accuracy of the five screening methods for the diagnosis of high-grade CIN (CIN II and III) was compared in the different age groups. A joint model for the diagnosis using different combinations of the five methods was developed according to the analysis by the SAS 8.0 software. The model was used to evaluate the accuracy of the different combination programs for the diagnosis of high-grade CIN, and the results were confirmed by the histopathological examination.

RESULTS

The sensitivity and specificity of the single screen method (TCT, HPV test, detection of the TERC and C-MYC genes, and VIA/VILI method) for CIN II was 80.9, 70.2, 72.3, 76.6, and 72.3%, as well as 98.0, 95.1, 96.3, 96.3, and 90.4%, respectively. The sensitivity of the single screening method in four different age groups (25-34, 35-44, 45-54 and 55-66 years) was as follows: TCT, 64.3, 90.9 76.5, and 85.7%; HPV test, 78.6, 72.7, 60.0, and 71.4%; the TERC gene, 50.0, 90.9, 80.0, and 71.4%; the C-MYC gene, 50.0, 90.9, 80.0, and 100%; VIA/VILI, 85.7, 81.8, 66.7, and 42.9%. The specificity was: TCT, 98.9, 98.1, 98.8, and 95.2%; HPV test, 96.7, 95.1, 92.2, and 100%; the TERC gene, 95.0, 98.9, 94.0, and 95.2%; the C-MYC gene, 97.2, 97.3, 93.4, and 97.6%; VIA/VILI, 91.2, 90.5, 89.8, and 88.1%, respectively. In the joint model for the diagnosis using different combinations, we found Logit (P) = 5.757 - 4.055 × TCT - 3.724 × HPV. The sensitivity and specificity in the combination program with TCT (primary screening) and HPV testing (adjunct screening) were 78.7 and 99.5%, while in the combination with HPV (primary) and TCT (adjunct), they were 53.2 and 99.7%, respectively. However, in the cytology-HPV parallel test, they were 97.9 and 93.4%. The ROC analysis revealed that the cytology-HPV parallel test is superior to the combinations of either TCT (primary) and HPV (adjunct) or HPV (primary) and TCT (adjunct; AUCTCT-HPV parallel test = 0.956; AUCTCT/primaryHPV/adjunct = 0.764).

CONCLUSIONS

Opportunistic cervical cancer screening is a practical approach to improve the efficiency of cervical cancer screening. Although the accuracy of TCT is the highest of the five screening methods for the diagnosis of high-grade CIN, it is still subject to sample acquisition and the practitioner's skill and experience. Since the efficacy of VIA/VILI may vary in all ages, it is not recommended for menopausal and perimenopausal women.

Which are more correctly diagnosed: conventional Papanicolaou smears or Thinprep samples? A comparative study of 9 years of external quality-assurance testing

BACKGROUND

The Royal College of Pathologists of Australasia Cytopathology Quality Assurance Program offers external testing in gynecologic cytology to Australasian and international laboratories. Laboratory interpretation of conventional Papanicolaou (Pap) smears is compared with interpretation of liquid-based cervical cytologic (ThinPrep) samples.

METHODS

Conventional Pap smears and ThinPrep samples were distributed to participating laboratories annually over 9 years (from 2004 to 2012), and a range of entities was tested. Target responses and major error rates and diagnostic trends over time were explored.

RESULTS

In total, 23,373 conventional Pap smears and 14,104 ThinPrep samples were reported. Both Australasian (P = .003) and international (P < .001) laboratories achieved a higher percentage of the target diagnosis of squamous dysplasia with ThinPrep samples. Australasian laboratories more accurately diagnosed endocervical adenocarcinoma in situ with conventional smears (P = .036), whereas international laboratories performed better with ThinPrep samples (P = .006). Sampling of the lower uterine segment was more accurately diagnosed by both Australasian (P < .001) and international (P = .001) laboratories using conventional Pap smears. Significant improvements in achieving the target diagnosis over time for squamous dysplasias using both modalities were observed for Australasian and international laboratories (P < .001 for both). There was improvement in diagnosing high sampling using ThinPrep for both groups (P = .001 and P = .015, respectively). Australasian performance declined over time in reaching the target of normal (no infections) for both conventional (P = .001) and ThinPrep (P < .001) techniques and for international laboratories with the ThinPrep technique (P < .001).

CONCLUSIONS

Participation in external proficiency testing in cervical cytology allows an analysis of performance, the identification of areas of diagnostic difficulty, a review of trends over time, and the highlighting of topics for ongoing education.

Screening for cervical cancer using automated analysis of PAP-smears

Cervical cancer is one of the most deadly and common forms of cancer among women if no action is taken to prevent it, yet it is preventable through a simple screening test, the so-called PAP-smear. This is the most effective cancer prevention measure developed so far. But the visual examination of the smears is time consuming and expensive and there have been numerous attempts at automating the analysis ever since the test was introduced more than 60 years ago. The first commercial systems for automated analysis of the cell samples appeared around the turn of the millennium but they have had limited impact on the screening costs. In this paper we examine the key issues that need to be addressed when an automated analysis system is developed and discuss how these challenges have been met over the years. The lessons learned may be useful in the efforts to create a cost-effective screening system that could make affordable screening for cervical cancer available for all women globally, thus preventing most of the quarter million annual unnecessary deaths still caused by this disease.

Test execution variation in peritoneal lavage cytology could be related to poor diagnostic accuracy and stage migration in patients with gastric cancer

PURPOSE

Peritoneal lavage cytology is part of the routine staging workup for patients with advanced gastric cancer. However, no quality assurance study has been conducted to show variations or biases in peritoneal lavage cytology results. The aim of this study was to demonstrate a test execution variation in peritoneal lavage cytology between investigating surgeons.

MATERIALS AND METHODS

A prospective cohort study was designed for determination of the positive rate of peritoneal lavage cytology using a liquid-based preparation method in patients with potentially curable advanced gastric cancer (cT2~4/N0~2/M0). One hundred thirty patients were enrolled and underwent laparotomy, peritoneal lavage cytology, and standard gastrectomy, which were performed by 3 investigating surgeons. Data were analyzed using the chi-square test and a logistic regression model.

RESULTS

The overall positive peritoneal cytology rate was 10.0%. Subgroup positive rates were 5.3% in pT1 cancer, 2.0% in pT2/3 cancer, 11.1% in pT4a cancer, and 71.4% in pT4b cancer. In univariate analysis, positive peritoneal cytology showed significant correlation with pT stage, lymphatic invasion, vascular invasion, ascites, and the investigating surgeon. We found the positive rate to be 2.1% for surgeon A, 10.2% for surgeon B, and 20.6% for surgeon C (P=0.024). Multivariate analysis identified pT stage, ascites, and the investigating surgeon to be significant risk factors for positive peritoneal cytology.

CONCLUSIONS

The peritoneal lavage cytology results were significantly affected by the investigating surgeon, providing strong evidence of test execution variation that could be related to poor diagnostic accuracy and stage migration in patients with advanced gastric cancer.

The significance of augmented high-grade squamous intraepithelial lesion detection on pap test examination: partial results from the RODEO study team

OBJECTIVE

This study sought to ascertain the significance of augmented high-grade squamous intraepithelial lesion (HSIL) detection by Pap test using both conventional smear and liquid-based cytology (LBC) in a high-risk population.

STUDY DESIGN

We conducted a direct-to-vial study to compare the diagnostic performance of Pap smear versus LBC in a high-risk population of women referred for colposcopy at a gynecologic ambulatory clinic at the Barretos Cancer Hospital in Brazil during 2011.

RESULTS

The detection of both low-grade squamous intraepithelial lesions (LSILs) and HSILs was significantly greater (p = 0.04 and p = 0.033, respectively) in the LBC arm [84 LSIL cases (5.7%) and 148 HSIL cases (10.1%)] than in the conventional smear arm [66 LSIL cases (4.1%) and 126 HSIL cases (7.9%)]; however, no differences were found for invasive squamous carcinoma or adenocarcinoma (p = 0.678). Of 3,071 women who were examined cytologically (1,604 conventional preparations and 1,467 LBC) and colposcopically, biopsies were available for 279 conventional preparations (17.6%) and 325 LBC preparations (22.2%). No significant differences were found between the methods with respect to diagnostic performance.

CONCLUSION

LBC was significantly superior to conventional smears for the detection of LSILs and HSILs, but these results did not influence biopsy confirmation. Both methods showed similar performances with high positive predictive values but very low sensitivities.

Cytological Evaluation and REBA HPV-ID HPV Testing of Newly Developed Liquid-Based Cytology, EASYPREP: Comparison with SurePath

Background

The objective of this study was to evaluate a newly-developed EASYPREP liquid-based cytology method in cervicovaginal specimens and compare it with SurePath.

Methods

Cervicovaginal specimens were prospectively collected from 1,000 patients with EASYPREP and SurePath. The specimens were first collected by brushing for SurePath and second for EASYPREP. The specimens of both methods were diagnosed according to the Bethesda System. Additionally, we performed to REBA HPV-ID genotyping and sequencing analysis for human papillomavirus (HPV) on 249 specimens.

Results

EASYPREP and SurePath showed even distribution of cells and were equal in cellularity and staining quality. The diagnostic agreement between the two methods was 96.5%. Based on the standard of SurePath, the sensitivity, specificity, positive predictive value, and negative predictive value of EASYPREP were 90.7%, 99.2%, 94.8%, and 98.5%, respectively. The positivity of REBA HPV-ID was 49.4% and 95.1% in normal and abnormal cytological samples, respectively. The result of REBA HPV-ID had high concordance with sequencing analysis.

Conclusions

EASYPREP provided comparable results to SurePath in the diagnosis and staining quality of cytology examinations and in HPV testing with REBA HPV-ID. EASYPREP could be another LBC method choice for the cervicovaginal specimens. Additionally, REBA HPV-ID may be a useful method for HPV genotyping.

Pooled analysis of the performance of liquid-based cytology in population-based cervical cancer screening studies in China

BACKGROUND

Liquid-based cytology (LBC) has been widely used for cervical cancer screening. Despite numerous studies and systematic reviews, to the authors' knowledge few large studies to date have focused on biopsy-confirmed cervical lesions and controversy remains concerning its diagnostic accuracy. The objective of the current study was to assess LBC for detecting biopsy-confirmed cervical intraepithelial neoplasia (CIN) and cancer.

METHODS

A pooled analysis of LBC using data from 13 population-based, cross-sectional, cervical cancer screening studies performed in China from 1999 to 2008 was performed. Participants (n = 26,782) received LBC and human papillomavirus testing. Women found to be positive on screening were referred for colposcopy and biopsy. The accuracy of LBC for detecting biopsy-confirmed CIN of type 2 or worse (CIN2+) as well as CIN type 3 or worse (CIN3+) lesions was analyzed.

RESULTS

Of 25,830 women included in the analysis, CIN2+ was found in 107 of 2612 with atypical squamous cells (4.1%), 142 of 923 with low-grade squamous intraepithelial neoplasia (15.4%), 512 of 784 with high-grade squamous intraepithelial neoplasia (65.3%), 29 of 30 with squamous cell carcinoma (96.7%), 4 of 27 with atypical glandular cells (14.8%), and 85 of 21,454 with normal cytology results (0.4%). No invasive cancers were found to have atypical squamous cells, atypical glandular cells, or cytologically normal slides. The overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of LBC for detecting CIN2+ were 81.0%, 95.4%, 38.3%, 99.3 %, and 94.9%, respectively. Although Hybrid Capture 2 was more sensitive than LBC, the specificity, positive predictive value, and overall accuracy of LBC were higher than those of Hybrid Capture2 at 85.2%, 18.6%, and 85.5%, respectively.

CONCLUSIONS

The results of the current study indicate that the performance of LBC can effectively predict the risk of existing CIN2+ and may be a good screening tool for cervical cancer prevention in a developing country.

Comparative study of the results from conventional cervico-vaginal oncotic cytology and liquid-based cytology

OBJECTIVE

To compare two oncotic cervical cytology techniques, the conventional and the liquid-based cytology, in low risk patients for uterine cervical cancer.

METHODS

Comparative prospective study with 100 patients who came to their annual gynecological exam, and were submitted simultaneously to both techniques. We used the McNemar test, with a significance level of p < 0.05 to compare the results obtained related to adequacy of the smear quality, descriptive diagnosis prevalence, guided biopsy confirmation and histology.

RESULTS

Adequacy of the smear was similar for both methods. The quality with squamocolumnar junction in 93% of conventional cytology and in 84% of the liquid-based cytology had statistical significance. As for the diagnosis of atypical cells they were detected in 3% of conventional cytology and in 10% of liquid-based cytology (p = 0.06). Atypical squamous cells of undetermined significance were the most prevalent abnormality. The liquid-based cytology performance was better when compared with colposcopy (guided biopsy), presenting sensitivity of 66.7% and specificity of 100%. There was no cytological and histological concordance for the conventional cytology.

CONCLUSIONS

Liquid-based cytology had a better performance to diagnose atypical cells and the cytohistological concordance was higher than in the conventional cytology.

Clinicopathologic importance of women with squamous cell carcinoma cytology on Siriraj liquid-based cervical cytology

OBJECTIVES

The purposes of this study were to determine the prevalence and predictive value to detect significant neoplasia and invasive lesions, and to evaluate the correlation between clinical and histopathology of women with squamous cell carcinoma (SCCA) on Siriraj liquid-based cervical cytology (Siriraj-LBC).

METHODS

The computerized database of women who underwent Siriraj-LBC at Siriraj Hospital, Mahidol University from January 2007 to December 2010 were retrieved. The hospital records of women with SCCA cytology were reviewed.

RESULTS

The prevalence of SCCA cytology was 0.07%. A total of 86 women, mean age was 58.1 years. Sixty-one women (70.9%) were post-menopausal. Overall significant pathology and invasive gynecologic cancer were detected in 84 women (97.7%) and 71 women (82.5%), respectively. The positive predictive values for detection of significant neoplasia and invasive lesion were 97.7% and 82.6%, respectively. The cervical cancer was diagnosed in 69 women and among these 58 women were SCCA. Thirteen women (15.1%) had cervical intraepithelial neoplasia (CIN) 3 and two women (2.3%) had cervicitis. The sensitivity and specificity of colposcopy for cervical cancer detection in SCCA cytology were 83.3% and 75%, respectively. Median follow up period was 17.6 months and 64 patients were alive without cytologic abnormality.

CONCLUSIONS

The final histopathology of SCCA cytology in our populations demonstrated a wide variety, from cervicitis to invasive cancer and the most common diagnosis was invasive cervical cancer. Colposcopy with biopsy and/or endocervical curettage and loop electrosurgical excision procedure should be undertaken to achieve histologic diagnosis.

Comparison of ThinPrep and SurePath liquid-based cytology and subsequent human papillomavirus DNA testing in China

BACKGROUND

Liquid-based cytology (LBC) has been compared with conventional cytology in numerous studies. In the current study of 2 LBC systems, the accuracy, rates of unsatisfactory cytology, and sufficiency of residual LBC specimens for Hybrid Capture 2 (HC2) HPV DNA testing were compared.

METHODS

Eligible women ages 30 to 49 years were recruited for this cross-sectional population-based study in rural China. Women were assessed by visual inspection with acetic acid (VIA), LBC, and high-risk HPV HC2 DNA assay. Cervical specimens were preserved according to SurePath or ThinPrep protocols. LBC results were manually read. HC2 testing was performed on specimens with sufficient residual volume. Colposcopies and biopsies were performed on women who were VIA positive at the time of initial screening. Women with abnormal LBC or HC2 test results were called back for colposcopies and 4-quadrant cervical biopsies.

RESULTS

Of 2005 eligible women, 972 were tested by SurePath and 1033 by ThinPrep. Compared with SurePath samples, ThinPrep samples had higher rates of unsatisfactory cytology (0.2% for SurePath and 1.5% for ThinPrep) and insufficient residual volume for HC2 (0.0% for SurePath and 18.2% for ThinPrep). SurePath samples yielded higher sensitivities and similar specificities for LBC and HC2 testing of residual specimens, but these differences were not determined to be significant by area-under-the-curve analysis (LBC performance: 0.89 for SurePath and 0.85 for ThinPrep; HC2 performance: 0.91 for SurePath and 0.89 for ThinPrep).

CONCLUSIONS

Both methods yielded similar validity in detecting significant cervical lesions. However, SurePath samples yielded higher rates of satisfactory LBC slides and sufficient residual volume for HC2.

Additional slides from residual ThinPrep Pap tests: Of potential diagnostic benefit in equivocal cases?

The aim of this study was to further evaluate the diagnostic significance of additional slides prepared from residual ThinPrep (TP) Pap Tests. Up to 10 repeat slides were prepared from 105 residual TP cervical samples. All additional slides were evaluated for the presence of diagnostic elements which were not found on the primary TP slide. After the evaluation of the repeat slides, an upgraded diagnosis was noted in 15 cases (14.3%). The reclassified cases included: three negative cases reclassified as two ASC-US and as one LSIL, seven cases of ASC-US reclassified as six LSIL and as one HSIL, and five cases of LSIL reclassified as HSIL. The highest rate (7/15 cases, 46.7%) of cases with an upgraded diagnosis was noted in the ASC-US diagnostic category. Our results suggest that repeat processing of residual TP cervical samples may represent an adjunctive diagnostic tool for a more accurate classification of ASC-US cases. Nevertheless, the practical value of this approach seems to be limited by its significant cost and its uncertain effectiveness.

Comparison of conventional and liquid-based cytology, and human papillomavirus testing using SurePath preparation in Japan

We compared the detection rate of cervical neoplasias between a liquid-based cytology (LBC) method using SurePath and the conventional method. We also studied the feasibility of human papillomavirus (HPV) typing by linear array assay. Cytological specimens from 1551 Japanese women were prepared using the conventional and SurePath methods; the cytological and histological results from biopsy samples were compared. HPV typing using an HPV linear array assay was carried out on residual specimens using the SurePath method. The cytodiagnostic results showed a concordance rate of 85.3% (Κ= 0.46) between the two methods. The sensitivity of lesions histopathologically diagnosed as CIN1 or above was not significantly different between the two methods (P = 0.575-1.000). The receiver operating characteristic curve analysis of the detectability in CIN2 or above revealed no significant difference between the two methods (P = 0.096). Among the 44 patients who underwent HPV typing using a linear array assay, 33 samples were eligible for HPV testing and were stored at ambient temperature. In conclusion, the SurePath and conventional methods have equivalent abilities for detecting cervical lesions. After preparation for cytological diagnosis, use of the remaining cells from the SurePath specimens to perform HPV typing using the linear array method could be feasible.