Gynecologic Cytology: Practical Considerations and Limitations

Liquid-based Papanicolaou tests in endometrial carcinoma diagnosis. Performance, error root cause analysis, and quality improvement

Recent reports show that the sensitivity of endometrial carcinoma detection on liquid-based Papanicolaou (Pap) tests (88%) is considerably higher than that reported on conventional Pap smears (20%-30%), although few laboratories have corroborated these results. We performed a 5-year retrospective review of all liquid-based Pap tests (n = 69) in women who later were given a diagnosis of endometrial carcinoma, performed error root cause analysis, and developed quality improvement initiatives as a means of error reduction. The original and rescreened Pap test sensitivity rates for endometrial carcinoma were 31.9% and 59.3%, respectively. Root cause analysis showed that poor specimen quality and cognitive failures contributed to a false-negative error in 67% (18/27) and 59% (16/27), respectively, of all cases. System analysis showed that latent factors contributing to error included lack of redundant and educational systems. We conclude that system redesign of liquid-based Pap test screening processes has the potential to improve sensitivity in endometrial carcinoma diagnosis.

Smear patterns and spectrum of premalignant and malignant cervical epithelial lesions in postmenopausal Indian women: a hospital-based study

Cervical cancer is one of the leading causes of morbidity and mortality among women but can be prevented through simple cost-effective measures, such as creating awareness, and regular screening with the Pap smear, both in the premenopausal and postmenopausal age group. This study was carried out to study the cervical smear patterns and type of cervical epithelial lesions in a group of postmenopausal Indian females and the relationship with clinical profile of patients. Pap smears were taken from 320 postmenopausal Indian females and meticulously screened. Lesions were classified according to type of postmenopausal pattern. 120 smears showed varying degrees of premalignant and malignant changes, which were classified using the Bethesda system. The findings were correlated with duration of menopause, parity, and duration of sexual activity and significance was derived. Histopathological correlation was conducted in those cases where biopsies were available. It was found that as the age of the patients increased, the incidence of low-grade and high-grade squamous intraepithelial lesions and carcinoma also increased with the relationship being statistically significant. The occurrence of these lesions also showed an association with increasing parity and period of sexual activity. Thus, it can be concluded that it is important to create widespread awareness about the necessity of regular screening, including the postmenopausal period. Conventional cytology or the Pap smear is a cost-effective and efficient method for screening of patients but requires training and experience to minimize errors. It is suitable for developing regions where costlier techniques are not in routine use.

Screening in gynecologic cancers

Gynecologic malignancies account for approximately 13% of cancers in women. Ovarian and uterine cancer are among the five most common causes of cancer deaths in women, exceeded in incidence only by cancers of the breast, colon, and lung. Improved survival in patients with genital cancers predominantly reflects early diagnosis and not improved treatments. Even cancers for which there are effective screening and satisfactory treatments are seen more often than is acceptable. It is paramount that those entrusted with the health of women be knowledgeable about all cancer screening techniques and be able to identify the patient at risk for gynecologic malignancy. The provider's obligation to be vigilant about the signs and symptoms of cancer must be matched by the patients' responsibility to her own health. Regular gynecologic examinations, Papanicolaou (Pap) tests, and immediate reporting of unusual signs and symptoms are requirements that cannot be dismissed by patients. Education directed toward patients and health care providers can optimize survival. The Pap test for cervical cancer remains a universally accepted screening procedure. Human papillomavirus (HPV) DNA typing, cervicography, loop electrosurgical excision procedure (LEEP), transvaginal ultrasonography, color flow doppler, endometrial sampling, and serum CA 125 measurements are some of the newer techniques being investigation as potential screening tools. Although additional prospective studies are needed to establish the value of these modalities, there is little doubt that prognostic information obtained from these modalities will influence the clinical care of patients in the near future.