The outcome for women with microinvasive cervical cancer with stromal invasion 1 mm or less: should we always re-excise?

To assess the management and outcome for women with microinvasive cervical cancer with stromal invasion 1 mm or less, examining the impact of re-excision. A retrospective cohort study with interval analysis performed between December 2000 and December 2010. Sheffield Gynaecological Cancer Centre and Jessop Wing Colposcopy Unit, Sheffield, UK. Women diagnosed with microinvasive cervical cancer with stromal invasion 1 mm or less during the allocated study period. Methods used is a retrospective cohort study. Risk of recurrence and mortality from disease; incidence of residual disease in repeat excision specimens. A total of 140 women were identified as having microinvasive cervical cancer with stromal invasion 1 mm or less. Sixty-three (45%) had a completely excised lesion; 77 (55%) had an incompletely excised lesion at first treatment. Fifty-five women underwent repeat excision. No residual disease was found in the majority (n=40; 73%). No women suffered disease recurrence or died from disease during the allocated study period. Outcome for women with microinvasive cervical cancer with stromal invasion 1 mm or less is excellent. Repeat excision is associated with very low rates of residual disease. A more conservative approach to follow-up incorporating HPV testing should be explored.

Rapid pre-screening is more sensitive in liquid-based cytology than in conventional smears.

Rapid pre-screening (RPS) is a useful tool to measure and improve performance in the cytology laboratory. Whether RPS is more or less effective in liquid-based cytology than in conventional smears is unknown. We compared the estimated sensitivity in a laboratory of 11 cytotechnologists which converted from conventional smears to SurePath™ (Becton Dickinson, Franklin Lakes, N.J., USA) liquid based cytology. In the 9 months prior to conversion, 23,286 smears were screened compared with 30,610 smears in the 12 months immediately after conversion. The estimated sensitivity of rapid pre-screening for 90 s improved significantly with liquid based cytology for all abnormalities (58.7 vs. 68.7%, p<0.001), atypical squamous cells of undetermined significance+low-grade squamous intra-epithelial lesion (52.6 vs. 63.1%, p<0.001), and high-grade squamous intra-epithelial alone (76.2 vs. 85%, p<0.001). Histologic follow up for 156 cases identified by rapid pre-screening of SurePath slides showed 32 (21%) cases of CIN1 or greater and 18 cases (12%) with CIN3 or worse. We conclude that rapid pre-screening is significantly more sensitive in liquid-based cytology compared with conventional smears, and detects significant lesions that are missed by routine screening.

Endometrial Adenocarcinoma in SurePath™ Cervical Samples: Cytological Features Revisited.

OBJECTIVE: The cytomorphological criteria of malignant endometrial lesions in cervical samples are less well described than those of cervical lesions. We wished to investigate if there were features in SurePath™ liquid-based cytology samples that would facilitate more accurate differentiation between benign and malignant endometrial cells. STUDY DESIGN: This was a two-phase study, with a review of all SurePath™ samples reported as endometrial adenocarcinoma (n = 42) evaluating 12 cytological features in the first phase. In phase 2 (test set), all initial cases plus an additional 83 cases were reviewed using these 12 cytological features to predict the outcome. RESULTS: Out of 12 cytological features evaluated in phase 1 (training set), nuclear chromatin pattern, apoptotic bodies and tingible body macrophages were found to be the most significant features determining malignant histological outcome. These 12 cytological features were re-evaluated in phase 2 (n = 125). Of 125 cases, 54 had a benign and 71 had a malignant or premalignant histological outcome, with a positive predictive value of 56.8%. CONCLUSION: Granular nuclear chromatin, tingible body macrophages and apoptosis in the background are the most significant factors in determining whether endometrial cells present in cervical samples represent malignancy or are benign. Using these features, relatively accurate predictions of endometrial pathology can be made.

Cytology in the diagnosis of cervical cancer in symptomatic young women: a retrospective review.

BACKGROUND: Cervical cancer in young women presents a diagnostic challenge because gynaecological symptoms are common but underlying disease is rare. AIM: To explore the potential for using cytology as a diagnostic aid for cervical cancer in young women. DESIGN AND SETTING: Retrospective review of primary care records and cytology data from the national cervical screening database and national audit of cervical cancers. METHOD: Four datasets of women aged 20-29 years in England were examined: primary care records and national screening data from an in-depth study of cervical cancers; cytology from the national audit of cervical cancers; whole-population cytology from the national screening database; and general-population primary care records from the Clinical Practice Research Datalink. The authors explored the sensitivity and positive predictive value (PPV) of symptomatic cytology (earliest <12 months before diagnosis) to cervical cancer. RESULTS: The estimated prevalence of cervical cancer among symptomatic women was between 0.4% and 0.9%. The sensitivity of moderate dyskaryosis (high-grade squamous intraepithelial lesion [HSIL]) or worse in women aged 20-29 years was 90.9% to 96.2% across datasets, regardless of symptom status. The PPV was estimated to be between 10.0% and 30.0%. For women aged 20-24 years, the PPV of '?invasive squamous carcinoma' was 25.4%, and 2.0% for severe or worse cytology. CONCLUSION: Cytology has value beyond screening, and could be used as a diagnostic aid for earlier detection of cervical cancer in young women with gynaecological symptoms by ruling in urgent referral.

Cervical cytology and the diagnosis of cervical cancer in older women.

OBJECTIVES: Most non-screen-detected cervical cancers are advanced stage. We assess the potential for cytology to expedite diagnosis when used outside of routine call and recall screening for cervical cancer. METHODS: Two cohorts of women with cytology that did not appear to have been taken as part of routine screening, nested within a census of cervical cytology, in England between April 2007 and March 2010 were studied: 93,322 women aged 40-69 at first cytology, and 14,668 women aged ≥70. The diagnostic performance of high grade cervical squamous intraepithelial lesion (HSIL) or worse cytology was estimated. We also estimated case-fatality from stage distribution in women aged ≥66 with and without cytology in the year prior to diagnosis. RESULTS: There were 259 cancers diagnosed in women aged 40-69 at first cytology, and 78 in women aged ≥70. The sensitivity of cytology ≥ HSIL for cancer was 89% and 83% respectively, and the number of women needed to test to identify one cancer was 404 (95% confidence interval [CI]: 355-462) and 226 (95% CI: 177-292) respectively. Women aged ≥66 with cytology within a year of diagnosis had earlier stage cancers than those without, corresponding to a 17-22% reduction in case fatality. CONCLUSIONS: Cervical cytology is an excellent identifier of cancer among women tested outside routine screening call and recall. Its use as a triage tool, for instance in women with vague gynaecological symptoms, could facilitate earlier stage diagnosis and reduce cervical cancer mortality.

Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion: diagnostic features in surepath™ cervical samples.

This study was undertaken to identify the situations in which a diagnosis of "Atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion (ASC-H)" is offered in SurePath™ cervical samples and to identify cytological criteria helpful in predicting high-grade disease. 2,335 (3.4%) SurePath samples reported as atypical squamous cells (ASC) over a period of 2 years, including 1,112 cases with known hrHPV status were retrieved. 105/1,112 cases were categorized into ASC-H, and slides were available for review in 88/105 cases. These 88 samples were divided into two categories based on follow-up histological outcome and hrHPV status-category A: cases with CIN2+ lesions on follow-up (n = 48) and category B: cases with ≤CIN1 lesions or hrHPV negative status (n = 40). 78% (82/105) cases of ASC-H tested positive for hrHPV. Overall CIN2+ lesions were found in 50.3% (53/105) cases. Of 88 cases reviewed, HCGs were noted in 56.3% (27/48) cases in category A and 75% (30/40) cases in category B. Dispersed metaplastic cells and scattered small atypical cells were seen in 37.5% (18/48) cases in category A and 12.5%(5/40) in category B. The majority of cases with dispersed atypical cells had <20 cells/sample and cases with HCGs had <10 HCGs per sample. The majority of the cases reported as ASC-H contained HCGs. Of these groups with nuclear crowding, disorganization and those with steep edges ("blocks") are likely to predict high-grade disease. The samples with only dispersed atypical cells had <20 cells/sample in majority of cases. In these, a disproportionate and especially high nuclear: cytoplasmic ratio and irregular chromatin were the most useful features in predicting high-grade disease.

Individual estimated sensitivity and workload for manual screening of SurePath gynecologic cytology.

Data correlating individual screening sensitivity in gynecologic cytology and workload is limited. We compared the estimated sensitivity of manual screening of SurePath slides with individual workload. Estimated sensitivity determined by rapid prescreening was correlated with total workload in a laboratory performing manual screening of SurePath preparations for a 1 year period. There were 12 CTs with a total daily workload ranging from 8-35 slides. The mean estimated sensitivity for SurePath was 97.0% (range 91-100%). The mean estimated sensitivity for the lowest half workload (8-23 slides/day) was significantly higher than that for the highest half workload (23-35 slides/day) (98.3 versus 95.7%, P ≤ 0.001). The highest workload that achieved 100% estimated sensitivity was 30 slides/day. For manual screening of SurePath slides, individual estimated sensitivity is correlated with workload even at relatively low daily workloads.

Improved sensitivity over time with rapid prescreening in gynecologic cytology.

Rapid prescreening (RPS) is a powerful tool to measure and improve performance in the cytology laboratory. Long-term use of RPS has been shown to result in improved sensitivity and precision in routine screening. The effect of long-term RPS on RPS itself is not known. We compared the sensitivity of 100% RPS of Surepath™ liquid-based cytology over a 4-year period in a laboratory of 11 cytotechnologists (CTs). In comparison with the first 2 years, RPS for the laboratory showed a significant increase in sensitivity for all abnormalities (72.2% vs. 67.3%, P < 0.001) and ASCUS + LSIL (68.5% vs. 62.1%, P < 0.001). For individual CTs s, the lowest sensitivity for all abnormalities increased from 59.0 to 63.2%, whereas, for HSIL, it increased from 71.4% to 75.0%. We conclude that long-term use of RPS leads to significant increase in the sensitivity of RPS.