Comparison of Performance of Conventional and ThinPrep Gynecologic Preparations in the College of American Pathologists Gynecologic Cytology Program

Evaluation of a real-time optoelectronic method in the diagnostics of CIN over four years of observations

Cervical cancer is considered to be particularly amenable to prevention and highly treatable in its early stages. The real-time optoelectronic method of cervix examination seemed to be very promising in the detection of cervical squamous intraepithelial lesions and demonstrated relatively good efficacy. Although this method was introduced into clinics almost 10 years ago, it has not found its place in diagnostic schemes. At the moment, cytological smears and HPV detection with genotyping are still essential. TruScreen seems to be a slightly forgotten test. The aim of the study was to evaluate the efficacy and accuracy of TruScreen in detecting cervical pathology: CIN and cervical cancer confirmed with a histopathological diagnosis in comparison with other methods–cytology and colposcopy over four years of observations. The study was conducted on 130 women with abnormal Pap smear results. We can conclude that a real-time optoelectronic method like TruScreen can be useful as an effective initial cervical cancer screening in developing countries, possibly in combination with other methods. The combination of cytology and TruScreen examination may help clinicians to take decision about the next diagnostics steps (e.g. colposcopy) and contribute to better primary screening for cervical cancer.

Epidemiological investigation on the cervical health of lesbians in Beijing, China

Objective

To investigate human papillomavirus (HPV) infection status and influencing factors among lesbians.

Methods

In August to October 2018, 300 lesbians were recruited in Beijing using snowball sampling. Sociodemographic characteristics, behavioural indices and HPV status were measured. Colposcopy was performed on participants with HPV genotypes 16 and 18 and on participants with other high-risk HPV subtypes and positive ThinPrep (TCT) results.

Results

The overall HPV-positive rate was 25%. High number of sexual partners, smoking, drinking, not using condoms and using sex toys during intercourse were identified as HPV infection risk factors. Of the HPV subtypes detected, 84% were high-risk HPV subtypes. The colposcopy results showed that 20 participants (80%) with HPV 16 and HPV 18 had cervical intraepithelial neoplasia I (CIN I) or above lesions. The colposcopy results also showed that 16 participants (64%) infected with other high-risk types of HPV virus and who had positive TCT results had CIN I or above lesions.

Conclusions

The cervical health of lesbians should not be neglected, and appropriate health education should be improved for this group.

THE VALUE OF GROSS VISUAL ASSESSMENT OF SPECIMEN ADEQUACY FOR LIQUID-BASED CYTOLOGY DURING ULTRASOUND-GUIDED, FINE-NEEDLE ASPIRATION OF THYROID NODULES

OBJECTIVE

Major problems of fine-needle aspiration (FNA) of thyroid nodules arise due to nondiagnostic results caused by inadequately obtained FNA specimens. The purpose of this study was to evaluate the value of visual assessment of liquid-based cytology specimens during FNA of thyroid nodules for predicting sampling adequacy.

METHODS

For 3 months, visual assessment of FNA specimens was used for 534 consecutive nodules in 534 patients. The FNA specimens were visually graded immediately following aspiration for each nodule, and the visual grades were classified into 2 categories: inadequate (<6 cell groups) and adequate (>6 cell groups). The cytology results were classified as diagnostic or nondiagnostic based on the Bethesda system. We compared the ultrasound features and FNA characteristics between the diagnostic and nondiagnostic results. Multiple logistic regression analysis was used to determine factors independently predictive of nondiagnostic results. We also evaluated the interobserver agreement regarding the visual assessment.

RESULTS

Visual assessment was feasible in all patients, and the nondiagnostic rate was 11.6% (62 of 534). Nondiagnostic results were more frequent in the inadequate visual assessment group (38.1%) than in the adequate visual assessment group (10.5%) (P = .001). Independent predictive factors for nondiagnostic results were inadequate visual assessment (odds ratio, 5.18), >50% vascularity (odds ratio, 3.98), and macrocalcification (odds ratio, 3.60). Interobserver agreement for the prediction of visual assessment was good (κ value, 0.767; P<.001).

CONCLUSION

Immediate visual assessment of a specimen during FNA of a thyroid nodule is a feasible method for predicting sampling adequacy.

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.

The feasibilities of TruScreen for primary cervical cancer screening: a self-controlled study

OBJECTIVE

Screening programs based on cytology testing led to the incidence reduction of cervical cancer mortality of about 70-80 % in industrialized countries. However, these favorable results have not been replicated in developing areas. Thus, we aim to evaluate the efficacy of TruScreen (Polartechnics, Sydney, Australia) in detecting of precancerous lesions in comparison with cervical cytology test.

METHODS

A total of 181 outpatients were screened by TruScreen using the pathological results as the gold standard. The medical records of cytological smear within 6 weeks were obtained from 169 of these participants. The reliability and yield of TruScreen and cytological smear were assessed. The screening results of TruScreen were compared with those obtained from the conventional smear.

RESULTS

The sensitivities for histologically confirmed cervical intraepithelial neoplasia (CIN) lesions by TruScreen and Pap, were 67.4 % (95 % CI 53.4-81.5) and 87.9 % (95 % CI 76.7-99.0), respectively. The specificities for histologically confirmed CIN lesions by TruScreen and Pap, were 68.1 % (95 % CI 60.3-75.9) and 74.3 % (95 % CI 70.0-81.4), respectively. In contrast to Pap smear, TruScreen was comparatively efficacious in screening of cervical cancer (χ (2) = 0.0133, P = 0.9081).

CONCLUSION

TruScreen is a potential test for initial cervical screening in developing world regions.

Capture of cervical exfoliative cells on a glass slide coated by 3-glycidyloxypropyl trimethoxysilane and poly-L-lysine

A new modification method for glass slides was developed and applied to make ThinPrep Pap smears, in order to increase the adhesion ability of cervical exfoliative cells. 3-glycidyloxypropyl trimethoxysilane (GOPS) was coated on the glass slides firstly on the slides, then poly-L-lysine (PLL) was covalently modified onto the above epoxy-terminated slides to form GOPS-PLL double decorated slides. The modified slides were characterized using X-ray photoelectron spectroscopy (XPS) and atomic force microscopy (AFM). The cell adhesion ability effect was tested and compared with traditional PLL coated slides by fixing the cervical exfoliative cells on the double adorned slides. The control test was conducted by the bare glass slides unmodified. The cell morphology of cervical exfoliative cells adhered on different slides was observed under the microscope after Papanicolaou staining. The number of cervical exfoliative cells on the unmodified slides, PLL coated slides and GOPS-PLL coated slides was 1030±300, 3283±226 and 4119±280 (n=12), respectively. The data among the three different modification methods showed significant differences (one-way analysis of variance, ANOVA test, P<0.05). The cell capturing effect of the GOPS-PLL slide was the best among the three different modified slides. In addition, the GOPS-PLL slide could enhance the uniformity of the adhered cells and be widely applied to the ThinPrep system for cervical carcinoma screening to increase the accuracy rate of diagnosis.

Application of TruScreen in detecting ASCUS patients

OBJECTIVE

To explore the application of cervical cancer screening system, TruScreen in detecting atypical squamous cell of undetermined significance (ASCUS) patients.

METHODS

A total of 42 cases were selected, who were diagnosed as ASCUS by thinprep cytologic test (TCT). Area from site 15 to 20, site 21 to 32 were detected by TruScreen. And the result was compared with those of cases which had positive pathological result of cervical biopsy.

RESULTS

There were 16 cases with abnormal pathological result in ASCUS cases, including 6 cases with cervical intraepithelial neoplasia (CIN) I, 6 cases with CIN II, 3 cases with CIN III and 1 case with infiltrating carcinoma. The consistency between TCT and pathological test was 38.10% (16/42). The positive rate of TruScreen at site 15-20 was 61.91% (26/42). There was significant difference in consistency with pathological test between TCT and TruScreen (x(2)=4.762, P=0.029). The positive rate of TruScreen at site 21-32 was 66.67% (28/42)(Kappa=0.181, P=0.016). There was significant difference in consistency with pathological test between TCT and TruScreen (x(2)=9.4919, P=0.002). And no case was missed when site 21-32 of patients with CINII and above were detected by TruScreen.

CONCLUSIONS

TruScreen is effective in detecting ASCUS patients.

Human Papillomavirus and Pap Smear

High-risk human papillomavirus (HPV) infection and viral persistence is a major risk factor in the development of squamous intraepithelial lesions and invasive carcinoma of the cervix. In the United States, deaths due to squamous cell carcinoma of the cervix have fallen by 75% since the 1960s because of Papanicolaou (Pap) smear screening. However, the traditional Pap had a sensitivity of about 70% for detecting clinically significant precancerous lesions and cancer because of sampling and interpretive errors. The introduction of 2 liquid-based Pap smear collection systems in the 1990s, the use of HPV testing as a triage and co-testing with Pap smear, and the introduction of 2 automated screening devices have had a significant impact on improving the detection of such precancerous lesions. This review provides an analysis of the changes in Pap smear collection, improvements in screening, the evolutionary changes of high-risk HPV testing, reporting terminology of Pap smears, and clinical management guidelines. The future impact of 2 prophylactic HPV vaccines on the incidence of cervical carcinoma is also discussed. This article also discusses alternatives such as primary screening for high-risk HPV testing with visual inspection for cervical cancer detection used in resource-poor settings with a high incidence of cervical cancer.

Image-guided ThinPrep Papanicolaou tests and cotesting with high-risk human papillomavirus in women aged 30 years and older in a low-risk private practice population

BACKGROUND

Screening for cervical cancer precursors has evolved considerably with the introduction of new technologies to improve the early detection of disease. The objective of this study was to analyze the accuracy and effectiveness of combined screening with cytology and high-risk human papillomavirus (HR-HPV) testing in a low-risk population of women aged >or=30 years.

METHODS

Consecutive unselected samples from a group of 1871 women aged >or=30 years were screened with image-guided ThinPrep tests and HR-HPV tests during a 6-month period. Histologic follow-up was reviewed among women with positive HR-HPV tests.

RESULTS

A total of 85 (4.5%) women had positive HR-HPV tests. In 48 HR-HPV-positive women with follow-up biopsies, 41 (85%) were found to have histologic abnormalities. Thirty-three (1.9%) women with cytologically normal Papanicolaou (Pap) tests harbored HR-HPV, and a cervical intraepithelial neoplasia (CIN) 2+ lesion was detected in 1 (16%) of 6 women with histologic follow-up. Conversely, 2 (28%) of 7 women with high-grade intraepithelial lesion on cytology tested negative for HR-HPV during the same period. A case of serous carcinoma with atypical glandular cells on cytology was also negative for HR-HPV, as expected.

CONCLUSIONS

In this low-risk population of women aged >or=30 years, histology-confirmed CIN2+ lesions were identified in women with negative cytology and positive HR-HPV tests, as well as in those with positive cytology and negative HR-HPV tests. Because both cytology and HPV testing alone missed significant lesions, cotesting with Pap and HR-HPV in women aged >or=30 years appears to be a reasonable option in a low-risk population.

Who receives, benefits from and is harmed by cervical and breast cancer screening among Hong Kong Chinese?

BACKGROUND

To estimate the proportion of and characterize women who had received cervical and breast screening and to quantify the associated preventable burden of disease and potential iatrogenic harm.

METHODS

A total of 3484 Hong Kong Chinese women were interviewed in person. Screening prevalence and associated predictors, disability-adjusted life-years (DALYs), the numbers of false-positive tests and the resultant confirmatory procedures and related complications were estimated.

RESULTS

A total of 6.2% of women (>or=18) reported regular pap but no mammography or clinical breast examination (CBE) as per local evidence-based guidelines, whereas among women aged >or=40 years, 5.2% reported regular screening by all three modalities and 55.3% had never been screened for either cancer. Women who underwent regular health checkups were consistently the most likely to have been screened, as were younger, married and socially advantaged respondents. Triennial pap screening would save 708 DALYs annually, or 528 more DALYs compared with the status quo. However, this would generate 28,600 repeat smears and 390 colposcopies from false-positive screens. Opportunistic mammographic screening averted 100 DALYs currently, but could have potentially reduced a further 546 with biennial screening. Mass screening mammography (CBE) would lead to 33,700 (20,200) false-positives per year requiring 29,900 (8300) repeat mammograms or ultrasonograms, 6800 (3000) biopsies and 620 (270) biopsy-related complications.

CONCLUSIONS

Screening uptake patterns are suboptimal. By making explicit the possible risks and benefits based on this template, policy makers in developing Asia with a similar female cancer burden may be able to use the information to make evidence-based decisions that are consistent with local circumstances, values and preferences.

Accuracy of herpes simplex virus detection in liquid-based (SurePath) Papanicolaou tests: a comparison with polymerase chain reaction

A review of our institution's Papanicolaou test records over an 11-yr period showed that liquid-based Papanicolaou tests (LBPTs) had a significantly higher frequency of diagnoses of Herpes simplex virus (HSV)-related cellular changes compared to conventional Papanicolaou smears (77/302,841, 0.026% vs. 56/376,173, 0.015%, P = 0.002). To investigate the accuracy of the diagnosis of HSV by LBPT, we performed conventional polymerase chain reaction (PCR) on the residual samples from 258 prospectively collected LBPT and real-time PCR using a different primer set on a subset of 40 LBPT. Conventional PCR was positive in 22 of 22 cases diagnosed of HSV, 1 of 2 cases diagnosed as suspicious for HSV, and none of 234 LBPT without a cytologic HSV diagnosis. Real-time PCR was positive in 8 of 8 cases diagnosed as HSV and none of the 32 controls. We conclude that LBPT allows an increased detection of HSV that is highly accurate.

Barriers to adoption of recent technology in cervical screening

The Pap smear is one of the modern success stories in the field of preventive medicine. Since its introduction as a screening test, there has been a dramatic reduction in the incidence of cervical cancer. However, the search for a better screening test continues. The new technologies, including liquid-based cytology (LBC), Human Papilloma Virus (HPV) testing and automated or machine-assisted screening have been introduced. However, there is continuous debate about whether society's limited resources are better spent on reaching the underserved rather than on these technologies. Another question is whether these technologies create yet another kind of disparity in delivering preventive care. For example, despite the wide use of LBC (99% of tests submitted to our laboratory are LBC), conventional Pap smears are still used to screen/follow up some women. It is not clear why some providers continue to prefer conventional smear over LBC and what are the barriers for adopting LBC in cervical cancer screening. We hypothesize the lower cost of conventional compared to LBC Pap testing, patient's lower socio-economic indices, a patient's medical history and provider's subspecialty/training all appear to play a role in the choice of using conventional Pap testing rather than LBC. Unintentionally, this choice results in repeat testing, delayed treatment and potentially higher costs than intended. The ultimate goal of this review article is to understand and explore possible barriers and disparities to adopting new technology in cancer screening.

Atypical parakeratotic spires and HCII HPV results: correlation in liquid-based cervicovaginal cytology specimens interpreted as ASC-US

The 2001 Bethesda System (2nd edition) indicates that parakeratosis with nuclear enlargement, hyperchromasia, irregular contours, and/or three dimensionality should prompt consideration of an interpretation of ASC-US or greater. The authors retrospectively reviewed 812 liquid-based cervicovaginal cytology samples (CVCSs) interpreted as ASC-US during an 11-month period. All slides were studied for the presence or absence of atypical parakeratotic spires (APKSs), a specific form of atypical parakeratosis. Results from corresponding Hybrid Capture II high risk (HR) HPV testing were recorded (blinded). Of 812 women, 28% (230/812) had APKSs and 20% (163/812) had positive HCII assays for HR HPV. Three percent of all reflexed ASC-US vials (26/812) had both APKSs and positive HR HPV assays (sensitivity = 16%, specificity = 69%). APKSs in liquid-based CVCSs interpreted as ASC-US do not independently correlate to a positive reflex test for HR HPV (P < 0.0001). This suggests that APKSs are most often unrelated to underlying HR HPV infection. The finding of APKSs alone in CVCSs does not warrant an interpretation of SIL and should be used only in concert with other findings to label a sample as ASC-US.

Virtual microscopy for cytology proficiency testing: Are we there yet?

BACKGROUND

The objective of this study was to investigate the potential of virtual microscopy (VM) as an avenue for the delivery of mandatory cytology proficiency tests).

METHODS

Three senior cytotechnologists and 2 board-certified cytopathologists participated in 3 virtual proficiency tests. Each set consisted of 10 ThinPrep slides that were digitized by an Aperio T3 ScanScope. The cytologic diagnoses covered the range of interpretive guidelines provided by the Centers for Medicare and Medicaid Services (CMS). Each cytotechnologist followed the requirement of a primary screener with the cytopathologists utilizing the secondary screener option.

RESULTS

Analysis of the diagnostic interpretation of the first proficiency test showed correct classification of 100% of normal and abnormal cells for primary and secondary screeners. The second proficiency test analysis revealed a 93.3% correct classification (100% using CMS guidelines) among the primary screeners. The secondary screeners gave a 100% correct classification. The final proficiency test had primary screeners and secondary screeners with 100% correct classification.

CONCLUSIONS

The current results confirmed the feasibility of VM for proficiency tests with 2 main problems noted. First, primary screeners had difficulties meeting the mandatory time allocation; however, with increased familiarity with the software, the screening times decreased. Second, the 3-dimensional nature of certain lesions made them difficult to interpret even on monolayered, liquid-based preparations. Creation of a more user-friendly software interface and better methods to capture depth of focus should make this a valid measure of cervicovaginal cytopathologic interpretive competence.

Ontario Cervical Cancer Screening Clinical Practice Guidelines

OBJECTIVE

To develop clinical practice guidelines for cervical screening and the primary management of abnormal cytology in Ontario, using an established methodological process.

DATA SOURCES

Primary data sources were relevant articles listed in the Medline (1998 to July 2004), Embase (1998 to July 2004), and Cochrane Library (2004, Issue 2) databases.

STUDY SELECTION

Studies addressing quality or the optimization of cervical screening were considered eligible in the systematic review of the evidence. Specifically, clinical practice guidelines, technology assessments, systematic reviews, and randomized controlled trials were of primary interest. Given the variability of the data, other information sources were considered eligible if there was a demonstrated gap in the published literature.

DATA EXTRACTION

Data were identified and extracted by a methodologist and reviewed by four authors. Results were reviewed and discussed by members of an expert working group consisting of a diverse group of health professionals with expertise in cervical cancer. Data audits were conducted by independent reviewers.

DATA SYNTHESIS

recommendations with evidence ratings were developed through a review of the evidence with expert consensus and were approved by more than 80% of 40 external practitioners who reviewed the document and responded to a standardized survey.

CONCLUSION

The development of comprehensive recommendations on cervical screening in Ontario was feasible using a rigorous methodological process. Recommendations for practice are provided.

Comparison of conventional Papanicolaou smear and SurePath liquid-based cytology in the Copenhagen population screening programme for cervical cancer

OBJECTIVE

To compare diagnostic performance of conventional Papanicolaou smear with SurePath liquid-based cytology in a population screening programme.

METHODS

A retrospective comparison was performed on data from two 18-month periods of the screening programme for cervical cancer in the municipality of Copenhagen with conventional Papanicolaou technique (n = 82,116) and liquid-based cytology (n = 84,414).

RESULTS

After the conversion to liquid-based cytology the percentage of unsatisfactory samples decreased from 2.3% to 0.3% (P < 0.001), whereas the number of normal cervical samples lacking an endocervical component increased from 8.5% to 8.9% (P < 0.005). The percentage of samples with atypical cells and cells suspicious for malignancy increased from 3% to 4.2% (P < 0.001) and from 1.9% to 2.4% (P < 0.001), respectively. The subsequent histological follow-up showed normal findings decreased from 70.5% to 68.9% and from 28.0% to 26.1%, respectively. However, in relation to the entire screening populations, there was an increase of normal findings from 2.12% to 2.89% after primary atypical diagnosis and from 0.53% to 0.62% after diagnosis of suspicious cells after conversion to the liquid-based technique.

CONCLUSIONS

This study showed the number of unsatisfactory samples to be significantly reduced with the liquid-based technique. The data suggest that there is an increased detection rate of cervical precancerous lesions with liquid-based cytology, but the number of false positive tests is still high. The specificity of the two tests seems similar, but this cannot be ascertained exactly, because of the fact that follow-up of negative cases is unavailable.

The significance of certification in liquid-based cytology and performance in the college of american pathologists interlaboratory comparison program in cervicovaginal cytopathology

CONTEXT

Morphology training and certification provided by the manufacturer is required before laboratories are allowed to prepare and interpret liquid-based cytology (LBC) gynecologic slides. Whether this certification is associated with improved LBC interpretation performance is not known.

OBJECTIVE

To determine whether LBC certification correlates with performance.

DESIGN

The results of the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytopathology for the year 2004 were reviewed. During this year a question on the answer form asked participants whether they were certified in LBC preparations. Participant responses were analyzed at 2 levels of agreement with the reference diagnosis of unknown glass slides mailed quarterly.

RESULTS

For cytotechnologists and pathologists, participants who were LBC certified had a significantly lower total discordant rate to series than participants who were not certified for validated LBC ThinPrep (Cytyc Corp, Marlborough, Mass) preparations (P < .001 for both groups). The results were similar for validated conventional preparations for pathologists but not for cytotechnologists. The differences were present across most individual diagnostic series. Differences were most striking for low-grade squamous intraepithelial lesions. In addition, cytotechnologists and pathologists who were certified had a significantly lower total discordant rate to the exact diagnosis for validated LBC ThinPrep slides than those who were not certified (discordant rates for cytotechnologists, 14.14% and 23.36%, respectively, P < .001; for pathologists, 15.99% and 24.07%, respectively, P < .001).

CONCLUSION

Although not all confounding factors were excluded in this study, LBC certification is associated with a significantly lower discordant rate to both series and exact diagnosis for validated LBC ThinPrep preparations.

The potential for failure in gynecologic regulatory proficiency testing with current slide validation criteria: results from the College of American Pathologists Interlaboratory Comparison in Gynecologic Cytology Program

CONTEXT

Current regulatory proficiency testing scoring results in an automatic failure for identifying high-grade squamous intraepithelial lesion (HSIL) as negative.

OBJECTIVE

The College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology data from January 2004 to April 2005 were analyzed to estimate the percentage of failure based on negative responses for HSIL and validation criteria.

DESIGN

More than 15,000 participants received field-validated and educational slide sets for conventional, ThinPrep, and SurePath modules. Educational sets fulfilled the validation criteria of the Center for Medicare and Medicaid Services, which required the consensus diagnosis of biopsy-proven HSIL (not field-validated) after review by 3 pathologists. The College of American Pathologists field validation required at least 20 responses to the HSIL+ series, with 70% matched to HSIL+ (standard error < or = 0.05). Minimum regulatory proficiency testing failure estimates were based on incorrect negative responses for the reference category of HSIL.

RESULTS

For both cytotechnologists and pathologists, there was a statistically significant higher failure rate for slides that were not field-validated versus those that were field-validated. In conventional modules, 5.3% of the slides that were not field-validated were called negative, versus 1.2% of the field-validated slides. In all liquid-based preparations, 4.0% of the non-field-validated versus 2.2% field-validated slides were called negative. Pathologists would have failed more often than cytotechnologists for the slides that were not field-validated, whereas there was no statistical difference in failure performance with field-validated slides.

CONCLUSIONS

Failures were significantly greater with the slides that were not field-validated for both conventional and liquid-based preparations (ThinPrep only) and have implications for both regulatory proficiency testing and expert legal review. Poor performance of pathologists relative to that of cytotechnologists may reflect a lack of prescreening of slides or scope of practice issues.

Dutch solutions for liquid-based cytology: analysis of unsatisfactory slides and HPV testing of equivocal cytology

The liquid-based techniques to obtain microscopy slides for cervical screening have replaced conventional smears almost completely in the USA, but not in all European countries. The decision making process to use liquid-based cytology (LBC) for nationwide screening programs depends on the health system. In a pilot study of over 7,000 screenees, we analyzed the unsatisfactory LBC slides and tested the equivocal cytologies for HPV by using the LiPA test. For comparison over 48,000 conventional screening data were used. Compared to conventional smears, the LBC slides were highly cellular, the state of fixation was much better, and obscuring blood did not exist. The unsatisfactory rate showed an increase from 262/100,000 (conventional smears) to 357/100,000 (LBC slides) due to too thick, undiagnosable epithelial fragments on the LBC slides. HPV testing of the equivocal cytology leads to a better patient management and less unnecessary referrals.

Comparative study of the ThinPrep Pap test and conventional cytology results in a Canadian cohort

OBJECTIVE

To compare the frequency of Pap test results in a prospective series of direct to vial ThinPrep tests to a cohort of conventionally prepared tests. To follow-up all test results for a minimum of 2 years and assess performance based on this outcome.

METHODS

All women presenting for either routine screening or colposcopic examination in 2001 were enrolled in the ThinPrep cohort. A similar, population of conventionally prepared tests was extracted from the year 2000 laboratory data. Information on all concurrent and follow-up cervical specimens over the ensuing 2 years was retrieved.

RESULTS

The ThinPrep cohort comprised 2288 Pap tests and the conventional, 2211. The frequency of normal [within normal limits (WNL) and benign cellular changes (BCC)] results in the ThinPrep cohort was 6% lower and the frequency of abnormal [> or =atypical squamous cells of undetermined significance (ASCUS)] results was 6.8% higher. Respective ThinPrep and conventional cohort results were 1156 (51%) and 1291 (58%) WNL, 625 (27%) and 561 (25%) BCC, 101 (4%) and 65 (3%) ASCUS, 21 (1%) and 2 (0.1%) atypical glandular cells of undetermined significance, 301 (13%) and 224 (10%) low-grade squamous intraepithelial lesion (LSIL), and 74 (3%) and 40 (2%) high-grade SIL (HSIL) (P < 0.0001). Follow-up was available for nearly 80% of each cohort. LSIL or higher was confirmed in 57.5% (n = 266) of the abnormal ThinPrep and 60.9% (n = 190) of the abnormal conventional tests. The ThinPrep yield of confirmed tests however was almost 50% higher than the conventional test.

CONCLUSION

In this population, ThinPrep was superior to the conventional Pap test.

Performance of cytology and human papillomavirus testing in relation to the menstrual cycle

Cervical smears prepared around the time of menses have been linked to unsatisfactory specimens and false negative results; however, it is unclear whether liquid-based cytology is similarly affected and data relating date of last menstrual period (LMP) to human papillomavirus (HPV) DNA testing are conflicting. Accordingly, we evaluated liquid-based cytology and HPV test results using Hybrid Capture 2 and PCR by LMP (days 0-10; 11-21; 22-28). We studied 5060 participants in ALTS, the Atypical Squamous Cells of Undetermined Significance (ASCUS) Low Grade Squamous Intraepithelial Lesion (LSIL) Triage Study. On average, women had 3.4 examinations (median 4, range 1-5) during a 2-year period of observation permitting an examination of intra-individual variation in cytology and HPV by LMP. Although uncommon, unsatisfactory cytology specimens were most likely on days 0-10. For satisfactory specimens, the frequency with which cytologic categories were reported varied by time since LMP, although differences were modest and did not affect the chance of abnormal cytology or its severity among women diagnosed with CIN2+. The frequency of positive HC2 tests did not vary with date of LMP. Among HPV infected women, independent of eventual diagnosis and the number of viral genotypes present, mid-cycle specimens yielded the highest frequency of LSIL cytologic interpretations and the highest HPV load; however, the magnitude of these effects were small. Intraindividual correlations of cytology or HPV by LMP were generally weak. We conclude that mid-cycle specimens yield slightly higher HPV DNA loads and slightly increased LSIL interpretations, but the clinical impact is marginal. Standardizing collection times would slightly improve interpretation of trends in HPV load. Finally, these data are consistent with the view that the biological properties of the HPV-infected cervix vary with the date of the LMP.

Liquid-based cytology improves productivity in cervical cytology screening

OBJECTIVES

The ThinPrep test was introduced into our institution on a phased basis over 3 years between January 2002 and December 2004. This study set out to assess its effect on productivity (as measured by output of cases per medical scientist per day) during the changeover period. Numbers of high and low-grade lesions and of unsatisfactory slides were also monitored.

METHODS

The percentage conversion from conventional preparation to liquid-based cytology (LBC) and output of cases per medical scientist per day were calculated from our database at 6-month intervals. The average backlog, average number of cases received per month and percentage of unsatisfactory and abnormal cases were calculated similarly.

RESULTS

Over the study period 92 084 cases were received. The percentage of cases using ThinPrep increased: from 9% in January 2002 to 73% in December 2004. During the study there was an increase in output from 17.0 to 22.3 cases per medical scientist per day, representing a 31% improvement at 73% conversion. Numbers of unsatisfactory cases decreased substantially and the numbers of low and high-grade diagnoses were relatively constant.

CONCLUSIONS

The change to ThinPrep has improved productivity and decreased the number of unsatisfactory cases. There was no adverse effect on quality during the changeover.

Papanicolaou Tests With Mixed High-Grade and Low-Grade Squamous Intraepithelial Lesion Features: Distinct Performance in the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytopathology

Context.—Previous studies have shown that in gynecologic cytology, cases of low-grade squamous intraepithelial lesion (LSIL) and high-grade squamous intraepithelial lesion (HSIL) perform differently on interpretive review. The performance of cases with mixed LSIL and HSIL features is unknown.

Objective.—To compare the performance of gynecologic cytology cases of “pure” LSIL and HSIL with cases showing mixed LSIL and HSIL features.

Design.—We compiled performance data from the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytopathology from the years 2003 and 2004, and compared the performance of slides showing relatively pure LSIL and HSIL (≤10% misclassification as HSIL and LSIL, respectively) with slides showing mixed LSIL or HSIL features (cases misclassified as LSIL or HSIL &gt;10% of the time).

Results.—Interpretations from a total of 4508 cases (2452 HSIL and 2056 LSIL) were analyzed. Overall, the sensitivity of participants on slides with a reference diagnosis of HSIL was 97.3%, and of LSIL was 95.9%. Performance trends for pure versus mixed cases varied by slide type and reference diagnosis. For conventional slides, participant sensitivity on pure HSIL cases was greatest (98.0%) and on pure LSIL cases was least (95.2%), while participant performance on cases with mixed features was intermediate (97.0% for mixed HSIL and 96.7% for mixed LSIL). In contrast, participant performance on ThinPrep slides showed the greatest sensitivity for mixed LSIL slides (97.9%), while performance on mixed HSIL slides showed the lowest sensitivity (95.7%); slides with pure features had intermediate sensitivity levels (96.3% for both HSIL and LSIL). Further evaluation demonstrated that conventional pure HSIL slides performed significantly better than mixed HSIL slides (P = .006), whereas mixed LSIL slides performed better than pure LSIL slides (P = .01). For ThinPrep slides, pure HSIL cases performed similarly to mixed HSIL cases (P = .43), while mixed LSIL cases performed better than pure LSIL cases (P = .04).

Conclusion.—Slides with mixed LSIL and HSIL features have measurably distinct performance characteristics in comparison to slides with pure LSIL or HSIL features. Participant performance on conventional mixed cases is distinctly different from performance on ThinPrep mixed cases.

Decreasing incidence of cervical adenocarcinoma in Ontario: Is this related to improved endocervical Pap test sampling?

In many developed countries, the incidence of cervical cancer has decreased. These reductions have been specific to squamous cell carcinoma (SCC) and have not included adenocarcinoma (AC). Incidence of AC has increased steadily over the last 20 years. The intent of this article is to examine trends in cervical adenocarcinoma incidence in Ontario over a 20-year period in relation to screening practices. All cases of cervical cancer between 1981 and 2002 were extracted from the Ontario Cancer Registry (a population-based, provincial-wide database). Age-standardized incidence rates were calculated overall, by broad age groups and by morphological type (SCC and AC). Time trends were assessed using JoinPoint methodology. In Ontario, opportunistic cervical cancer screening has been accompanied by significantly decreased rates of SCC since at least 1981. Conversely, the incidence of AC rose by 3.1% per year (95% CI: 1.6%, 4.6%) between 1981 and 1995, and subsequently declined by 4.0% per year (95% CI: -7.4%, -0.5%). From the mid- to late-1990s, instructions were distributed to clinicians, reinforcing the importance of dual specimen collection (i.e., using both spatula and endocervical brush). At the same time, laboratories routinely provided physicians with kits that included both spatula and brush. The subsequent decline in AC incidence may be due, in part, to improved specimen collection. As well, the decline may be partly due to increased awareness of AC precursors among cytopathologists and clinicians, and/or improvements in laboratory training and quality assurance.

Trouble in the office: liability issues in ambulatory care

Most clinicians are keenly aware of the liability risks associated with adverse birth outcomes for mother and/or infant. This level of awareness and concern also needs to extend to the day-to-day management of office practice. Clinicians who care for healthy women and their families may see abnormalities infrequently. The low yield of abnormal results means that close monitoring is essential to prevent overlooking the rare abnormal finding. This article focuses on three areas of liability risk for midwives and others who practice in the ambulatory setting: 1) inadequate tracking of test and referral results, 2) failure to diagnose, and 3) poor communication. Although none of these issues are limited to the ambulatory setting, only office practice is addressed in this article.

Altered recognition of reparative changes in ThinPrep specimens in the College of American Pathologists Gynecologic Cytology Program

CONTEXT

Previous studies have shown that the diagnosis of reparative changes in conventional smears in the College of American Pathologists Interlaboratory Comparison Program in Gynecologic Cytology is one of the least reproducible diagnoses. Indeed, the diagnosis of reparative changes consistently yields the highest false-positive rate of any negative for intraepithelial lesions and malignancy (NILM) cytodiagnostic category. It is unknown whether cytologists recognize reparative changes in ThinPrep specimens as well, or less often, as in conventional smears.

OBJECTIVE

To assess and compare the ability of cytologists to recognize reparative changes in conventional and ThinPrep preparations.

DESIGN

We compiled performance data from the College of American Pathologists Interlaboratory Comparison Program in Gynecologic Cytology from the 2000-2003 program years. More than 400 slides with a reference diagnosis of reparative changes met our study criteria, representing a total of 11 200 individual responses for conventional cases and 1155 individual responses for ThinPrep specimens. We evaluated the results of both individual and laboratory participants using 2 performance criteria: the false-positive discordancy rate and the exact match error rate (any response that does not exactly match the reference diagnosis of 120 [reparative changes]).

RESULTS

Cases with a reference diagnosis of reparative changes made up 1.2% of all ThinPrep slides and 3.7% of all conventional slides in circulation. The false-positive discordancy rate of individual responses on educational slides for conventional smears was significantly higher than the corresponding false-positive discordancy rate for ThinPrep specimens (15.7% for conventional vs 7.1% for ThinPrep specimens, P < .001). Laboratory responses on educational conventional smears and ThinPrep slides showed a similar trend (14.2% for conventional smears vs 2.4% for ThinPrep slides, P = .002). The exact match error rate on educational conventional slides was 41.4% for individual responses, while on educational ThinPrep slides, the overall error rate was 57.5% (P < .001). For laboratory responses, the exact match error rate was 40.5% for educational conventional smears versus 58.9% for educational ThinPrep smears (P < .001). Characteristic features of reparative changes were identified in ThinPrep specimens.

CONCLUSIONS

In the College of American Pathologists Interlaboratory Comparison Program in Gynecologic Cytology, ThinPrep slides with a reference diagnosis of reparative changes have a lower false-positive discordancy rate than conventional slides. Responses to ThinPrep cases with a reference diagnosis of reparative change show a higher exact match error rate than conventional smears. Since reparative changes in gynecologic cytology are recognized as indicating an increased risk of significant lesions, the clinical significance of these altered patterns of recognition of reparative changes in ThinPrep specimens warrants further investigation.

Cytologic features of low-grade squamous intraepithelial lesion in thinprep papanicolaou test slides and conventional smears: comparison of cases that performed poorly with those that performed well in the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology

CONTEXT

Both conventional and ThinPrep Papanicolaou smears with high-grade squamous intraepithelial lesions that are frequently missed are known to have relatively few abnormal cells. Whether this is also true of cases of low-grade squamous intraepithelial lesion is not known.

OBJECTIVE

To compare the cytologic features of cases of low-grade squamous intraepithelial lesion that perform poorly with the features of cases that perform well.

DESIGN

The cytologic features of 10 ThinPrep Pap Test and conventional smear cases of low-grade squamous intraepithelial lesion that performed poorly in the College of American Pathologists Interlaboratory Comparison Program were compared with 46 ThinPrep Pap Test and conventional smear cases that performed extremely well. The numbers of abnormal cells were categorized into less than 50, 51 to 100, 101 to 250, 251 to 500, and more than 500.

RESULTS

The median number of abnormal cells for cases that performed poorly was less than 50, whereas the median number of abnormal cells for cases that performed well was between 101 and 250. Overall, cases that performed poorly were significantly more likely to have less than 50, less than 100, and less than 250 abnormal cells than cases that performed well (P < .001, P < .001, and P = .009, respectively). A minority of cases performed well even with very few abnormal cells and groups. The same findings were present when conventional smears and ThinPrep specimens were analyzed separately.

CONCLUSIONS

ThinPrep Pap Test cases and conventional smears with a diagnosis of low-grade squamous intraepithelial lesion that perform poorly in this program have significantly fewer abnormal cells than those that perform well. The median number of abnormal cells in cases that performed well is lower than that of comparable high-grade cases in the program.

Results of the implementation of liquid-based cytology-SurePath in the Ontario screening program

BACKGROUND

The objective of the current study was to evaluate the adequacy and detection rates of SurePath after its implementation in Ontario.

METHODS

The detection and adequacy rates of the SurePath liquid-based cytology system (SP-LBC) were calculated for manually reviewed slides of the year 2002. The adequacy and detection rates from this study group were compared with a historical conventional smear (CS) group from the same laboratories during the same period of the previous year.

RESULTS

The SP-LBC study group consisted of 352,680 specimens with cytodiagnoses and the CS group included 378,990 specimens. The unsatisfactory rate for SP-LBC (0.24%) was less than that of the CS group (0.58%). The detection rate of atypical squamous cells (ASC+) by the SP-LBC group (4.69%) was greater than that of the CS group (3.81%), as was the detection rate of low-grade squamous intraepithelial lesions (LSIL+; 2.13% vs. 1.50% in the CS group). There was only a trend toward increased detection of high-grade squamous intraepithelial lesions (HSIL+) in the SP-LBC group (0.34%) relative to the CS group (0.31%), because the detection rate for carcinoma by SP-LBC declined.

CONCLUSIONS

The implementation of SP-LBC has been followed by better specimen adequacy and detection rates for ASC+, LSIL+, and a trend of increased detection of HSIL+ relative to CS practice. To determine sensitivity rates, a histopathologic database for cervical carcinoma and precancer needs to be established.

Resolving ASCUS without recourse to HPV testing: Manual reprocessing of residual automated liquid-based cytology (ALBC) material using manual liquid-based cytology (MLBC)

We show that residual cell material from ThinPrep PapTest (Cytyc Corporation, Boxborough, MA) atypical squamous-cells of undetermined significance (ASCUS) cases may be manually reprocessed to triage women into actionable diagnostic categories (HSIL, LSIL, and Negative). Material remaining from each of 358 ThinPrep ASCUS cases was manually reprocessed as two slides, labeled "A" and "B." Interobserver agreement between case contributors (CCs) and three sequential reviewers (SRs) was analyzed with 186 cases (Study 1), and diagnostic reproducibility between SRs was examined with an additional 172 cases (Study 2). In Study 1, CCs classified 33% of cases as LSIL or greater, SRs classified 60% as LSIL or greater, and there was 58% diagnostic agreement between CCs and SRs. No "Negative" case assignment by one group afforded an "HSIL" assignment by the complementary group. In Study 2, there was 95% agreement between SRs A slide and B slide diagnoses with 54% of A slides and 55% of B slides classified as LISL or greater. Again, no "Negative" case assignment to one slide afforded an "HSIL" assignment to the complementary slide. Overall, 12.6% of the 358 cases showed HSIL, and all HSILs by one observer group were ASCUS or greater by the complementary observer group. Using manual reprocessing beyond the 21-day specimen outdate for HPV testing by the Hybrid Capture II High Risk HPV test (HR-HCII; Digene Corporation, Beltsville, MD), many ThinPrep ASCUS cases were reclassified as LSIL or HSIL. The 12.6% HSIL proportion of this study approximated the 11.5% CIN 2 or greater proportion of the ALTS ASCUS arm. Similar to ALTS, manual liquid-based cytology (MLBC) would have referred nearly 60% of women to colposcopy for a definitive diagnosis of HSIL or LSIL without resorting to HPV testing. These data demonstrate that many cases of automated liquid-based cytology (ALBC)-diagnosed ASCUS represent unrecognized SIL, which is present in the ALBC specimen vial at the time the ASCUS diagnosis is rendered.

Cytologic features of high-grade squamous intraepithelial lesion in ThinPrep Papanicolaou test slides: comparison of cases that performed poorly with those that performed well in the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology

CONTEXT

Conventional Papanicolaou (Pap) test slides of high-grade squamous intraepithelial lesions (HSILs) that are frequently misdiagnosed are known to have relatively few dysplastic cells. Whether this is true of cases of HSIL in ThinPrep Pap Test specimens is not known.

OBJECTIVE

To determine if cases of HSIL in ThinPrep specimens that are frequently missed have relatively few dysplastic cells.

DESIGN

The cytologic features of 16 ThinPrep cases of HSIL that performed poorly in the College of American Pathologists Interlaboratory Comparison Program were compared with 22 ThinPrep Pap Test cases that performed extremely well.

RESULTS

Significantly more cases that performed poorly had fewer than 250 dysplastic cells (13/16) than cases that performed well (3/22) (P <.001).

CONCLUSION

ThinPrep Pap Test cases with a diagnosis of HSIL that performed poorly in this program had significantly fewer dysplastic cells than those that performed well.