Bone tumor radiograph review by pathologists prior to pathologic diagnosis: a receiver operator curve analysis of diagnostic utility

OBJECTIVE: To assess the performance of quick rescreening as an internal quality control for cervical smears previously screened as negative and to compare this method with clinically indicated rescreening of negative smears and with further 10% random rescreening. STUDY DESIGN: In a small-workload laboratory with many different types of indications for cytology, during a three-month period, all gynecologic cytology smears considered negative for significant findings (anything above atypical squamous cells of undetermined significance (ASCUS)/atypical glandular cells of undetermined significance (AGUS) in the Bethesda System) or inadequate were quickly rescreened using a 10 x objective. RESULTS: Of the total 2,188 smears processed, 164 (7.5%) were excluded from rapid review because they were positive on routine screening, and 2,024 cases were subjected to rapid rescreening: 1,925 (95.1%) cases were considered negative and 99 (4.9%) positive for significant findings; 58 of the latter were confirmed and 41 not confirmed by the cytopathologist's detailed examination. The 58 confirmed cases were classified as: 43 ASCUS/AGUS, 14 of low grade squamous intraepithelial lesion and 1 of invasive cancer. No cases of high grade squamous intraepithelial lesion were detected. CONCLUSION: Considering that the routine screening and internal quality control of the laboratory had detected 117 positive cases, the additional 58 represent a definite increase in the efficiency of a small-workload laboratory. In such a clinical setting, no additional case of a high grade lesion was detected by rapid rescreening. The increase in cost and time was considered very reasonable, and the method was incorporated as quality control for the laboratory. Clinically indicated rescreening of negative smears and random 10% rescreening after random rescreening did not add significantly to quality assurance.     

Significant reduction in the rate of false-negative cervical smears with neural network-based technology (PAPNET Testing System)

False-negative cervical Pap smears may lead to disability or death from carcinoma of the uterine cervix. New computer technology has led to the development of an interactive, neural network-based vision instrument to increase the accuracy of cervical smear screening. The instrument belongs to a new class of medical devices designed to provide computer-aided diagnosis (CADx). To test the instrument's performance, 487 archival negative smears (index smears) from 228 women with biopsy-documented high-grade precancerous lesions or invasive cervical carcinoma (index women) were retrieved from the files of 10 participating laboratories that were using federally mandated quality assurance procedures. Samples of sequential negative smears (total 9,666) were retrieved as controls. The instrument was used to identify evidence of missed cytological abnormalities, including atypical squamous or glandular cells of undetermined significance (ASCUS, AGUS), low-grade or high-grade squamous intraepithelial lesions (LSIL, HSIL) and carcinoma. Using the instrument, 98 false-negative index smears were identified in 72 of the 228 index women (31.6%, 95% confidence interval [CI]: 25% to 38%). Disregarding the debatable categories of ASCUS or AGUS, there were 44 women whose false-negative smears disclosed squamous intraepithelial lesions (SIL) or carcinoma (19.3%; 95% CI: 14.2% to 24.4%). Unexpectedly, SILs were also identified in 127 of 9,666 control negative smears (1.3%; 95% CI: 1.1% to 1.5%). Compared with historical performance data from several participating laboratories, the instrument increased the detection rate of SILs in control smears by 25% and increased the yield of quality control rescreening 5.1 times (P < 0.0001). These data provide evidence that conventional screening and quality control rescreening of cervical smears fail to identify a substantial number of abnormalities. A significant improvement in performance of screening of cervical smears could be achieved with the use of the instrument described in this report.     

Evaluation of the PAPNET system for prescreening triage of cervicovaginal smears

OBJECTIVE: To assess the PAPNET System for prescreening triage of cervical smears. STUDY DESIGN: We prospectively prescreened 5,170 consecutive cervicovaginal smears with the PAPNET System. The slides were then manually screened by cytotechnologists blinded to the PAPNET diagnoses. Cases identified as abnormal by either PAPNET or manual screening were reviewed by a cytopathologist. The PAPNET and manual diagnoses were correlated. RESULTS: Diagnostic concordance between PAPNET and manual screening was seen in 4,340 (84%) of the cases (3,167 negative, 1,038 abnormal and 135 unsatisfactory). Noncorrelation between PAPNET and manual diagnosis occurred in 794 cases (543 abnormal by PAPNET and negative manually, 228 negative by PAPNET and abnormal manually, 8 abnormal by PAPNET and unsatisfactory manually, 29 unsatisfactory by PAPNET and negative manually, 7 negative by PAPNET and unsatisfactory manually). The diagnostic sensitivity of the PAPNET System was 82%, diagnostic specificity 85%, predictive value of a positive test 66% and predictive value of a negative test 93.4%. The false negative fraction of PAPNET was 6.4% for low grade squamous intraepithelial lesion and above. CONCLUSION: PAPNET performed effectively for prescreening triage, increasing the accuracy of screening and reducing the screening time.     

Effects of information on the reinforcing, subjective, and psychomotor effects of nitrous oxide in healthy volunteers

One method of quality control which has recently been recommended by professional bodies in the UK is the 'rapid review' method. This involves the microscopic 30 s review of all negative cervical smears with the intention of flagging potential missed abnormalities. Although it has been suggested that rapid review is better than 10% random rescreening of negative smears, the efficiency and efficacy of this method of quality control have not been thoroughly evaluated. We have used the AxioHOME system, which can record the area of a slide covered and the screening time, to investigate slide coverage during rapid review quality control, as performed by 15 cytoscreeners and MLSOs reviewing a test set of 22 slides each. The test set comprised 18 negative slides, three positive slides, and one unsatisfactory slide. We have recorded two distinct methods of rapid review in use amongst cytotechnologists, the step method and the whole slide method. The data show that rapid review takes longer on average than the recommended 30 s, the mean screening times being 76 s and 82 s for the step and whole slide methods, respectively. Abnormal smears were missed on three of 15 occasions by the step method (sensitivity 80%, positive predictive value 85%), and on seven of 30 occasions by the whole slide method (sensitivity 76.6%, positive predictive value 45%). However, the 95% confidence intervals were wide (57.7-90.7% for the step method, and 51.9-95.7% for the whole slide method). Analysis of scanning tracks and screening rates shows significant flaws in the methodology of rapid review. Abnormal cells were not identified, although dyskaryotic cells were included in the scanning track on nine occasions, seven using the whole slide method and two using the step method. On one occasion (using the step method) abnormal cells were not identified because they were not included in the scanning track. Further research is in progress to determine optimal methods of rapid review, and whether the rapid review technique is as effective as automated screening systems for quality assurance in cytology.     

Microwave staining of enteric neurons using cuprolinic blue (Quinolinic phthalocyanin) combined with enzyme histochemistry and peroxidase immunohistochemistry

OBJECTIVE: To evaluate routine use of the NeoPath AutoPap 300 QC System (AP 300) as it influences diagnostic quality and operations in a large cytology laboratory. STUDY DESIGN: During a three-month period, 35,143 conventionally prepared consecutive cervical cytologic smears taken from non-high-risk women and evaluated as negative by our staff of 25 cytotechnologists were selected for processing by four AP 300 instruments. Slides flagged for review by the AP 300 were reevaluated by our five quality control (QC) cytotechnologists. False negative (FN) results were compared with results of our current practice (CP), random-selection QC method, used during the preceding six months. RESULTS: A 240% increase was seen in the FN detection rate for atypical squamous cells of undetermined significance (ASCUS) and squamous intraepithelial lesions (SIL) (n AP = 65 FN in 5,034 QC, n CP = 77 FN in 22,052 QC) and a 744% increase in the FN detection rate for low and high grade SIL (n AP = 24 FN/5,034 QC, n CP = 12 FN/22,052 QC). The rate of overcall by cytotechnologists did not increase. The QC ASCUS/SIL ratio improved. FN biopsy correlation increased from 45% to 85% (n CP = 17/38 agreement, n AP = 23/27 agreement). Turnaround time increased by one or more days for negative and 1.5 days for QC result reporting. Sensitivity varied among instruments. CONCLUSION: More FN results and greater specificity were seen using the AP 300 than using CP. As with other instrumentation, each laboratory should establish acceptable ranges of performance and baseline values for sensitivity and specificity.     

Evaluation of PAPNET--a semiautomated system used in the screening against cervical cancer

The PAPNET-system is a current example of automated technological progress in the pathological laboratory field. As the first Department of Pathology in Denmark, we have tested the applicability of this semi-automatical screening system in screening against cervical cancer. 3000 prospectively selected cervical smears were entered into the project. 1500 of these were first prescreened by the use of PAPNET and the negative slides were then manually rescreened. The remaining 1500 slides consisted of manually screened smears diagnosed as negative or inadequate. They were subsequently rescreened by the use of PAPNET. We only found one false negative smear in each group. Compared with histological follow-up the diagnoses CIN 1-3 were histologically confirmed in both groups. The PAPNET-assisted screening of cervical smears is faster, more valid and less fatiguing than the conventional screening method. Nevertheless, our results show no diagnostic quality improvement by the use of PAPNET. This is probably due to a strict screening procedure and a limited work load of a maximum of about 40-50 slides per cytotechnologist a day in our laboratory.     

Scan optimization of gadolinium contrast-enhanced three-dimensional MRA of peripheral arteries with multiple bolus injections and in vitro validation of stenosis quantification

OBJECTIVE: Development of a method for semiautomated preparation of purified, representative and conventionally stained monolayer smears from bronchial secretions suitable for subjective and/or automated cytodiagnosis. STUDY DESIGN: Bronchial secretions from 50 patients with and 48 without carcinoma cells of different types were collected in Saccomanno's fixative. After routine pick-and-smear processing, residual material was subjected to a mucolytic agent (ammonium thioglycolate). Separation of cells was performed by differential centrifugation through aqueous sucrose. The pellet was automatically processed by the AutoCyte PREP system. RESULTS: Slides revealed well-preserved, slightly shrunken, homogeneously distributed cells devoid of mucus, cellular debris and bacteria in monolayer arrangement nearly without overlap. Granulocytes were eliminated to a large extent. Comparison with pick-and-smear specimens showed more tumor cells per square centimeter of slide surface in 100% of AutoCyte PREP slides. The number of tumor cells per AutoCyte PREP slide was higher in 46% and lower in 54%. Selecting slides at random and requiring at least 10 abnormal cells to establish a tumor diagnosis were achieved in 82.7% if only one, in 88.0% if two and 94.0% if seven or eight AutoCyte PREP slides were investigated. CONCLUSION: The semiautomated method yielded conventionally stained, purified monolayer smears from bronchial secretions with cellular morphology suitable for evaluation by cytologists and screening machines. Representativity of AutoCyte PREP monolayers was superior to that of pick-and-smear slides.     

Analysis of false-negative and underreported smears in the Florence district screening program for cervical carcinoma

AIMS AND BACKGROUND: To review false-negative or underreported (reactive changes, squamous or glandular atypia) smears performed in women developing histologically proven CIN2 or more severe lesions within 24 months and evaluate error causes. The study setting was the Florence District cervical cancer population-based screening: about 60,000 women age 25-60 years screened per year. METHODS: 118 false-negative or underreported cases were identified at screening files-cancer Registry matching, and the original smears were reviewed by six independent readers to judge smear adequacy and error type. RESULTS: Sampling errors (reported as inadequate, negative or less severe than CIN1 at review) accounted for 74% and screening/interpretation errors (reported as CIN1 or more severe at review) accounted for 26% of studied cases. Screening/interpretation errors were more likely ascribed to misinterpretation and underreporting than to misperception of cellular abnormalities. CONCLUSIONS: Quality control should above all address the problem of sampling adequacy. Due to the rarity of misperceived abnormalities (true screening errors), manual or automated rescreening of negative smears would not be an effective procedure for quality control.     

Costs of conventional radical radiotherapy versus continuous hyperfractionated accelerated radiotherapy (CHART) in the treatment of patients with head and neck cancer or carcinoma of the bronchus. Medical Research Council CHART Steering Committee

We have compared the results of targeted manual rescreening of 1211 randomly selected smears with the results of PAPNET-assisted rescreening of 1613 cervical smears, containing at least 6.3% low-grade squamous intraepithelial lesion (SIL). PAPNET diagnosis and the targeted rescreening diagnosis were compared with the initial report, issued on the corresponding smear. Reproducibility scores for inadequacy, presence of endocervical and endometrial cells, specific infections and squamous cell abnormalities were determined. The reproducibility scores for the diagnosis of inadequate smears and specific infections were lower with the PAPNET-assisted rescreening. The detection of squamous cell abnormalities was excellent for both methods (> 0.95), with a higher detection rate for false-negative smears with the PAPNET testing system.     

Interactive neural-network-assisted screening. An economic assessment

OBJECTIVE: To apply clinical effectiveness estimates of interactive, neural network-assisted (INNA) screening to economic cervical cancer screening models to assess the economic impact of using this technology. STUDY DESIGN: Estimates of the sensitivity of INNA screening were drawn from a recently completed comprehensive synthesis of the INNA literature and applied to the Computer Model for Designing CANcer ConTROL Programs-based Cervical Cancer Screen economic model. The economic analysis was conducted from a modified payer perspective using costs borne by payers combined with patient deductibles and copayments. Costs of treating cervical cancer were updated to 1997 values using the medical care component of the Consumer Price Index. The model was run for a cohort of women starting at age 20 and screened on a triennial schedule through age 75. RESULTS: In the primary analysis (sensitivity of unassisted manual examination assumed to be 85%), the ratios found in this investigation varied from approximately $35,000 to $80,000 per life year saved, with the preponderance of ratios < $50,000 per life year saved. These results were sensitive to estimates of sensitivity of unassisted manual screening but not to estimates of treatment costs. CONCLUSION: This investigation applied accuracy data on INNA rescreening to a model of the cost-effectiveness of cervical cancer screening. The results support the use of INNA rescreening as an appropriate expenditure of resources to identify missed cases of cervical epithelial abnormalities and potential cervical cancer.     

Use of the Thin Prep Pap Test in clinical practice

The Thin Prep Pap Test (Cytyc Corp., Boxborough, MA) received approval by the Food and Drug Administration in May 1996 as an alternative to the traditional conventional smear. The present direct-to-vial study assessed the utility of thin-layer technology for cervicovaginal screening in clinical practice. From May 1997-February 1998 (10 mo), 15,006 cervical smears were processed and evaluated; of these, 5,423 (36.1%) were conventional smears (CS) and 9,583 (63.9%) were Thin Prep slides (TP). Both methods were analyzed to compare specimen adequacy and detection rates of cervical lesions. The TP method reduced the "satisfactory but limited by" rate by 97% and the unsatisfactory rate by 63%. For low-grade squamous intraepithelial lesions (LSILs), TP slides yielded 3.6% (348/9,583) as compared to 0.98% (53/5,423) for CS, an increase of 267%. The TP method detected a threefold increase in the number of high-grade squamous intraepithelial lesions (HSILs) of 1.0% (100/9,583), as compared to 0.3% (17/5,425) for the CS group. The atypical squamous cells of undetermined significance/squamous intraepithelial lesion (ASCUS SIL) ratio was reduced by 54% in the TP group. In routine usage in our laboratory, the Thin Prep Pap Test yielded a significant increase in the detection of LSILs and HSILs as compared to conventional smears. Specimen adequacy was significantly improved.     

Rescreening in gynecologic cytology. Rescreening of 8096 previous cases for current low-grade and indeterminate-grade squamous intraepithelial lesion diagnoses--a College of American Pathologists Q-Probes study of 323 laboratories

OBJECTIVE: To quantitate, characterize, and analyze errors identified in the rescreening of previous gynecologic cytology specimens with original diagnoses of within normal limits or benign cellular changes for current cases diagnosed as low-grade squamous intraepithelial lesion or squamous intraepithelial lesion of indeterminate grade. DESIGN AND SETTING: College of American Pathologists Q-Probes laboratory quality improvement study in 323 laboratories. MAIN OUTCOME MEASURE: False-negative rate in cases rescreened as a result of a current cytologic diagnosis of low-grade squamous intraepithelial lesion or squamous intraepithelial lesion of indeterminate grade. RESULTS: A total of 8096 smears performed within the 5 years preceding the current examination were rescreened. Of the rescreened cases, 284 (3.5%) were reclassified as a squamous intraepithelial lesion or carcinoma, 474 (5.9%) as atypical squamous cells of uncertain significance, 7 (0.09%) as atypical glandular cells of uncertain significance or glandular intraepithelial lesion, and 39 (0.5%) as unsatisfactory. Ninety-three percent (261/280) of all false-negative cases were identified in cases from the previous 3 years. CONCLUSION: Rescreening archival cytology cases previously diagnosed as within normal limits or benign cellular changes for current cases diagnosed as low-grade squamous intraepithelial lesion or squamous intraepithelial lesion of indeterminate grade will identify screening and diagnostic errors. This may be a useful quality improvement monitor in many laboratories.     

A new triple stain for Helicobacter pylori suitable for the autostainer: carbol fuchsin/Alcian blue/hematoxylin-eosin

OBJECTIVE: To develop an inexpensive stain to simultaneously visualize gastric morphology and Helicobacter pylori. METHODS: Gastric biopsies were stained with Genta stain using manual methods, and with carbol fuchsin/Alcian blue/hematoxylin-eosin using an automatic slide stainer (Sakura DRS-601). Slides were then coded and interpreted by 2 pathologists. Helicobacter pylori was scored using a visual scale (0 [none] to 5 [maximum]). RESULTS: One hundred slides were scored; H pylori was present in 64%. Carbol fuchsin/Alcian blue/hematoxylin-eosin stain gave excellent demonstration of gastric morphology. All positive cases (score > or =2) were correctly interpreted. Thirty-six slides had a score of 1 (< or =2 bacteria per entire slide). Of these, 10 were scored negative by Genta stain and 12 were scored negative by the carbol fuchsin/Alcian blue/hematoxylin-eosin stain (P = not significant). Hematoxylin-eosin was significantly less accurate than either of the other 2 stains (P < .02). CONCLUSION: The carbol fuchsin/Alcian blue/hematoxylin-eosin (El-Zimaity) stain is an economical stain suitable for simultaneous visualization of H pylori infection and gastric morphology.     

Reproducibility and accuracy of the diagnosis of cervical intraepithelial neoplasia (CIN) in 15 Italian laboratories: a national pilot project. Development of new indices of diagnostic variability. National Work Group for the expert quality control in cervico-vaginal cytopathology

OBJECTIVES: To assess reliability and accuracy of cervical smear diagnoses, to evaluate the effectiveness of the participation in a programme of slide exchange in increasing reliability and to re-examine the agreement in discriminating between CIN 2 and CIN 3 (merged in High grade SIL in the Bethesda System). SETTING: 15 laboratories participating on a voluntary basis throughout Italy, for a period of 1 year. METHOD: Phase one: circulation of 40 slides including all main diagnostic categories; discussion of results by representatives of participating centres. Phase two: circulation of another 40 similar slides. For each slide, not only a diagnosis but also recommendations for further examinations and a judgment on diagnostic difficulty were asked. Common measures of reliability and accuracy and (the latter only for slides on which a consensus diagnosis was reached corresponding to the histological diagnosis) were calculated; three new indices of diagnostic variability were also computed. RESULTS: Consensus diagnosis among representatives of participating laboratories on about 90% of the slides was reached both in the first and in the second phase. On 3 slides it was impossible to reach a consensus diagnosis even among external referees. In both phases, the study showed a marked variability among diagnoses, recommendations and judgment on diagnostic difficulty and, on some slides, a worrying lack of reliability in the determination of precancerous lesions. The agreement on discrimination between CIN 1 and CIN 2 was low, but it was slightly better between CIN 2 and CIN 3. No significant relationship between accuracy and workload was found. External quality control or better said, continuous quality improvement activities are essential but should be conducted in a more systematic way with greater involvement of cytotechnicians.     

Clinical Significance of a cervical cytologic diagnosis of atypical squamous cells of undetermined significance. Favoring a reactive process or low grade squamous intraepithelial lesion

OBJECTIVE: To define the clinical significance of qualifying the cytologic diagnosis of atypical squamous cells of undetermined significance (ASCUS) as favoring either a reactive process or a low grade squamous intraepithelial lesion (LSIL) in an effort to provide management guidelines. STUDY DESIGN: A total of 118 consecutive nonpregnant women with a cytological diagnosis of ASCUS favoring either a reactive process or LSIL were evaluated in our colposcopy clinic by repeat cervical cytologic smear, colposcopy and colposcopically directed biopsies and/or endocervical curettage, as indicated. RESULTS: Of the 58 patients evaluated for a smear of ASCUS, favoring a reactive process, 5 (8.6%) had cervical intraepithelial neoplasia (CIN) CIN 1 documented by biopsy. None had a high grade lesion. Twenty-six (45%) of the 58 patients who had a cytologic diagnosis of ASCUS favoring a reactive process had a repeat smear that was normal. None was found to have CIN. Of the 60 patients who had a cervical diagnosis of ASCUS favoring LSIL, 9 (15%) had CIN 1 or CIN 2. Nineteen (32%) of the 60 patients who had a cytologic diagnosis of ASCUS favoring LSIL had a repeat smear that was normal. One of these patients had CIN 1 on biopsy. The sensitivity of a repeat smear, in this limited series, after an initial smear of ASCUS favoring a reactive process is 100%, while it was 66% after an initial smear of ASCUS favoring LSIL. CONCLUSION: This study showed that in our laboratory a cytologic diagnosis of ASCUS favoring either a reactive process or LSIL is associated with a very low risk that the patient is haboring CIN. In the patient whose initial smear shows ASCUS favoring a reactive process, a repeat smear that is normal is reassuring. The patient whose smear shows ASCUS favoring LSIL probably requires further evaluation even in the presence of a normal repeat smear.     

Social support among African-American adults with diabetes. Part 1: Theoretical framework

BACKGROUND: Atypical squamous cells of undetermined significance (ASCUS) is a cytopathologic term used to describe cases without specific pathologic substratum. Between 10-60% of ASCUS cases correspond to squamous intraepithelial lesions (SIL). METHODS: The objectives of this study were: 1) to detect the pathologic significance of ASCUS in study patients, 2) to determine whether PAPNET identifies these cases, and 3) to compare the results of PAPNET with those of a second conventional screening. One hundred and sixty-three consecutive patients with the cytologic diagnosis of ASCUS and adequate follow-up were selected. Of these, 111 patients had colposcopic lesions and biopsies were performed; in the remaining 52 cases colposcopy was negative, as were 3 consecutive annual Papanicolaou smears. In a blind review, all 163 cases were rescreened using PAPNET. A second manual screening was performed for comparison. RESULTS: One hundred and twenty-six of the 163 cases (77.3%) showed no SIL on biopsy or follow-up. Of the 37 pathologic cases, the diagnosis was koilocytosis (flat condyloma) in 13 cases (8%), cervical intraepithelial neoplasia (CIN) type I in 11 cases (6.8%) low grade SIL [LSIL] in a total of 24 cases [14.8%]), and CIN II-III or high grade SIL (HSIL) in 11 cases (6.8%). In the review using PAPNET, 57 previous ASCUS cases were classified correctly as negative, and 7 of 13 koilocytosis cases (54%), 9 of 11 CIN I cases (82%), and 7 of 11 CIN II-III cases (64%) were diagnosed correctly. In the second conventional screening, 74 cases were negative and 77 cases were ASCUS; only 3 of 13 koilocytosis cases (23%), 4 of 11 CIN I cases (36.4%) and 5 of 11 CIN II-III cases (45.5%) were reclassified correctly. CONCLUSIONS: Among 163 patients with ASCUS, 77.3% had no precancerous squamous lesions. Concordance with definitive diagnosis was more accurate in our study using PAPNET analysis (Kappa index [K] = 0.7158) than by second conventional screening (K = 0.4537). Furthermore, we reclassified 35% of smears as negative and 15% as SIL.     

Comparison of conventional PAP smears with thin layer specimen (liquid-based PAP test) and correlation with cytopathological findings with HPV status using the hybrid capture system

Cervical smears of 554 outpatients of a hospital were examined using a blinded, split sample match pair protocol for which a conventional PAP-smear (CS) was first prepared with Cervex brush and the reminder of the sample was used for the thin-layer-preparation (TLP) according to the manual CytoRich System. The preparations of the two methods were compared with respect to quality and to sensitivity for atypias. In addition the HPV status was determined on the same cell suspension in cases with borderline changes (BLC) and dysplasias including carcinoma using the Hybrid Capture System. The use of TLP reduced the proportion of suboptimal preparations by more than 50% (14.6% vs. 35%) and eliminated the only inadequate preparation registered in CS. The DSP detected more than twice as many dysplasias of all degrees as CS (3.4% vs. 1.4%) and reduced the proportion of BLC to one third (3.2% vs. 9.6%). The percentages of cases positive for high- and intermediate-risk HPV in preparations with BLC, LSIL and HSIL were 17, 62.5% and 100% respectively. The TL-method improves significantly the efficiency of PAP-smears and allows the typing of HPV which is of clinical importance for the management of low grade squamous intraepitelial lesions and borderline changes. The findings speak against the further use of CS for cervical screening.     

Haematopoietic response and bcl-2 expression in patients with acute myeloid leukaemia

In the Bethesda System for reporting cervicovaginal cytology results, 1 criterion for smear adequacy is an adequate squamous component. The accuracy of a cytologist's estimate that 10% of the slide is covered by squamous cells, the adequacy threshold, has not been determined. The percentage of the surface of a glass slide covered by squamous cells was independently estimated by 4 cytologists on 2 occasions by microscopic examination of 83 buccal smears prepared to display estimated coverage of 1% to 20% of the slide surface. The accuracy of visual estimates was compared with measurements by the TracCell System. Each observer made a third set of estimates after receiving 5 slides with known coverage. Median coverage by visual estimation ranged from 4% to 25%, but as measured by the TracCell system was 2%. Median estimated coverage was significantly different for 2 of 4 observers between first and second viewings and between all but 1 pair of observers. For all observers, it was significantly higher than the true coverage. A visual estimate of 10% coverage corresponded to a true median coverage of 3%. When provided with a physical standard, the median estimated coverage by 3 of 4 observers was not statistically different from the true coverage, and interobserver kappa values improved. Unaided visual estimation of the adequacy of squamous cell coverage is neither reproducible nor accurate. What most cytologists consider "adequate" coverage represents only 3% coverage. The availability of a physical standard dramatically increases reproducibility and accuracy.     

Diagnosis and therapy of cervical intraepithelial dysplasia in Austria: a survey

PURPOSE: To assess the present state of diagnosis, therapy and follow-up of cervical intraepithelial neoplasia (CIN) in Austria. MATERIAL AND METHODS: 100 questionnaires were sent to all departments of Gynecology and Obstetrics in Austria. The anonymous questionnaire consisted of 22 multiple choice questions. It was possible to choose one or more answers by ticking applicable boxes, with the option in individual cases of giving additional information in the form of free text. RESULTS: 55 (55%) departments returned their answered questionnaires, indicating growing consciousness of quality control in medicine. It was found that in the collection of cytologic specimens 67% of the departments used a wooden spatula and cotton swabs. Management of patients with Pap smears indicating low grade squamous intraepithelial lesion (LSIL) and abnormal colposcopy, in 36 (65%) departments consisted of punch biopsy for histological diagnosis. After 3 recurrent Pap smears indicating LSIL, 76% of the hospitals treated such patients by conization, regardless of the histological grade of the lesion. Following inadequate resection of CIN III by conization, operative management of patients was the most commonly used regimen. CONCLUSION: We regard the results of this survey as a basis for the development of further quality management strategies in the prevention, diagnosis and therapy of cervical intraepithelial neoplasia in Austria.     

Evaluation of the ThinPrep Pap test as an adjunct to the conventional Pap smear

OBJECTIVE: To evaluate the ThinPrep Pap test as an adjunct to the conventional Pap smear. DESIGN AND SETTING: Prospectively collected cervical samples were split for independent screening at a large specialised private gynaecological pathology practice in Sydney. MAIN OUTCOME MEASURES: Detection of additional significant abnormalities (cervical intraepithelial neoplasia 1, or more severe); changed management recommendations from "repeat smear in 12 months" or "...six months" to "colposcopy", a reduction in unsatisfactory reports. RESULTS: 35,560 paired (split-sample) conventional and ThinPrep slides were prepared. Significant abnormalities were detected in 724 conventional smears (2%). Additional significant abnormalities were found in 85 ThinPrep slides whose corresponding conventional smear was negative or unsatisfactory even after review, representing a 12% increase in the detection of significant abnormalities. As a result of the addition of ThinPrep, management recommendations were changed from "repeat smear in 12 months" or "...six months" to "colposcopy" for 89 of 1669 women whose conventional Pap smears showed minor non-specific changes or papillomavirus. There were 1258 conventional smears (3.5%) that were unsatisfactory compared with 235 ThinPrep slides (0.7%); for only 74 samples (0.2%) were both slides unsatisfactory. CONCLUSIONS: The addition of the ThinPrep Pap test improves detection and clinical management of cervical abnormalities, and reduces the number of unsatisfactory samples which would otherwise require repeat tests.