Prevalence of high-grade cervical intraepithelial neoplasia in women with persistent high-risk HPV genotypes and negative cytology.

INTRODUCTION: Primary HPV screening will be implemented into the English Cervical Screening Programme by 2019. Its impact upon women referred to colposcopy, with negative cytology but persistently positive high-risk HPV (hrHPV), remains unreported from UK Sentinel sites. HPV primary screening was introduced in Sheffield, UK in April 2013; this paper reports its impact on the service. METHODS: A retrospective cohort study was performed from June 2014 to July 2016 at the Jessop Wing Colposcopy Unit, Sheffield. UK. Data were obtained from the pathology and colposcopy databases and cross-referenced with case-notes and pathology results for women referred with persistently positive hrHPV, cytology negative samples. Patient demographics, hrHPV genotype, biopsy rates, histological diagnoses, management, and outcomes were collected and baseline statistics performed. RESULTS: During the study 1076 women were seen. Most frequent hrHPV genotypes were: hrHPV other, 41%; and HPV16, 33%. The majority (72%) were found to have normal colposcopy; 28% had an abnormal colposcopic assessment (11% low-grade; 11% high-grade; 6% inadequate). The majority were discharged (83%) and only 5% underwent LLETZ. No cancers were detected. High-grade cervical intraepithelial neoplasia (CIN) was found in 7%; overall risk of CIN2 was 1/29; 1/30 for CIN3. Presence of HPV16 was associated with a significantly higher risk of high-grade CIN; 1/9. CONCLUSION: This is the first study to report results for women referred to colposcopy with cytology negative, persistently positive hrHPV. Disease prevalence is low, although women with HPV16 have a significantly higher likelihood of high-grade disease compared to other HPV subtypes.

Cytology training in the UK: a training centre prospective.

Training in both cervical and non-gynaecological cytology in the UK has never faced a more challenging environment. A national reconfiguration of cervical cytology services has focussed resources on large centres and damaged the traditional links and overlapping roles within non-gynaecological cytology. The UK is now at significant risk of falling behind most European countries in the use of non-gynaecological cytology. The UK currently has five training centres which are approved by the NHS Screening programme for training in cervical cytology; the planned introduction of HPV primary screening and the subsequent dramatic reduction in cervical cytology workload will increase pressure on the remaining training schools. Funding is variable across the country as is the degree of diversification that training schools have undertaken to try to ensure a viable future. It is vital for the future of cytology in the UK that the strong network of training schools remain to ensure the quality of the laboratory service as the UK moves towards HrHPV primary screening. There is no doubt that the training school roles will change and new technology embraced to deliver training fit for the changing role of cytology in healthcare but this will require funding and recognition of the vital role the training centres play in the delivery of high quality training in both cervical and non-gynaecological cytology.

Evaluating cytology for the detection of invasive cervical cancer.

OBJECTIVE: To assess the sensitivity, the number needed to screen (NNS) and the positive predictive value (PPV) of cervical cytology for the diagnosis of cancer by age in a screening population. METHODS: A retrospective cohort of women with invasive cervical cancer nested within a census of cervical cytology. All (c. 8 million) women aged 20-64 years with cervical cytology (excluding tests after an earlier abnormality). From April 2007 to March 2010, 3372 women had cervical cancer diagnosed within 12 months of such cytology in England. The sensitivity of cervical cytology to cancer, NNS to detect one cancer and predictive values of cytology were calculated for various 'referral' thresholds. These were calculated for ages 20-24, 25-34, 35-49 and 50-64 years. RESULTS: The sensitivity of at least moderate dyskaryosis [equivalent to a high-grade squamous intraepithelial lesion (HSIL) or worse] for cancer of 89.4% [95% confidence interval (CI) 88.3-90.4%] in women offered screening was independent of age. At all ages, women with borderline-early recall or mild dyskaryosis on cytology (equivalent to ASC-US and LSIL, respectively, in the Bethesda system) had a similar risk of cervical cancer to the risk in all women tested. The PPV of severe dyskaryosis/?invasive and ?glandular neoplasia cytology (equivalent to squamous cell carcinoma and adenocarcinoma/adenocarcinoma in situ, respectively, in the Bethesda System) were 34% and 12%, respectively; the PPV of severe dyskaryosis (HSIL: severe dysplasia) was 4%. The NNS was lowest when the incidence of cervical cancer was highest, at ages 25-39 years, but the proportion of those with abnormal cytology who have cancer was also lowest in younger women. CONCLUSIONS: The PPV of at least severe dyskaryosis (HSIL: severe dysplasia) for cancer was 4-10% of women aged 25-64 years, justifying a 2-week referral to colposcopy and demonstrating the importance of failsafe monitoring for such patients. The sensitivity of cytology for cervical cancer was excellent across all age groups.

Does LLETZ excision margin status predict residual disease in women who have undergone post-treatment cervical cytology and high-risk human papillomavirus testing?

OBJECTIVE: This study looks at the importance of large loop excision of the transformation zone (LLETZ) excision margins and residual cervical intraepithelial neoplasia (CIN) in women undertaking high-risk human papillomavirus (hrHPV) test of cure (TOC). METHODS: A retrospective cohort study with interval analysis performed June 2007 and June 2012 on all women undertaking treatment for CIN and subsequent hrHPV TOC 6 months post LLETZ. RESULTS: Final analysis group comprised 2093 women treated by LLETZ (1396 completely excised; 697 incompletely excised). 298 out of 1794 women (13%) were hrHPV positive at TOC. Thirty-six women who failed TOC and attended colposcopy had residual CIN. No statistically significant difference existed between the completely and incompletely excised groups with regards to the detection of residual CIN at 6 months post-treatment. There was no correlation of margins of excision with hrHPV status at TOC. The overall cure rate at TOC was 98%. CONCLUSIONS: TOC pathways recommend subsequent follow-up in primary care. This study identified no safety issues with TOC pathways. We can no longer assess histological failure rates at 12 months; we, therefore, recommend that this measure of treatment failure be redefined for post TOC women. It seems time to question the benefits of routine excision margins reporting, in the absence of invasion, for treated CIN. Future reporting needs to be reconsidered by the Royal College of Pathologists.

High-risk HPV platforms and test of cure: should specific HPV platforms more suited to screening in a 'test of cure' scenario be recommended?

OBJECTIVE: When the Sheffield screening laboratory changed the high-risk human papillomavirus (hrHPV) platforms from hybrid capture 2(®) (HC2; Digene Ltd) and to cobas 4800(®) (Roche) an unexpected and substantial increase in the number of cytology-negative/hrHPV-positive test-of-cure (ToC) samples after large loop excision of the transformation zone (LLETZ) was noted. We explore the potential reasons for these increased rates and discuss the implications this may have on the English NHS cervical screening programme (CSP). METHODS: A retrospective cohort study with interval analysis between June 2007 and June 2012. RESULTS: ToC was performed on 1530 women with HC2 and 396 with cobas 4800: 95.1% and 92.4% of women had negative cytology at ToC in the HC2 and cobas4800 testing period, respectively. Of these 13.9% and 27.8% tested positive for hrHPV in the HC2 and cobas 4800 group, respectively (P = <0.0001). No clinically significant increase in the number of cases of cervical intraepithelial neolpasia (CIN) was detected by the cobas4800 test in spite of doubling the number of cytology-negative/hrHPV-positive ToC samples. CONCLUSIONS: As far as we are aware, this is the first study reporting potential differences between different HPV platforms currently available in the English programme. The immediate impact of this increase in rates of hrHPV detection with cobas4800 is an increased number of colposcopy referrals to our service. The NHSCSP needs to assess whether this increase is acceptable and, if not, whether specific HPV platforms more suited to screening in a ToC scenario should be recommended.

Factors contributing to false-negative and potential false-negative cytology reports in SurePath™ liquid-based cervical cytology.

OBJECTIVES: The characteristics of false-negative conventional cervical cytology smears have been well documented, but there is limited literature available for liquid-based cytology (LBC), especially SurePath™ samples. We aimed to assess the characteristics of false-negative SurePath LBC samples. METHODS: Over a period of 5 years, an audit of false-negative reports in SurePath cervical cytology was undertaken. In a workload of 183, 112 samples, 481 (0.3%) false negatives were identified using two routes: those detected by routine laboratory internal quality control (rapid pre-screening) (n = 463) and those reported as normal (true false negatives) with concurrent high-grade cervical histology (n = 18). Ninety-five false-negative cases with a subsequent biopsy reported as at least cervical intraepithelial neoplasia grade 2 (CIN2+) were reviewed for a number of different cytomorphological features. RESULTS: Of 95 samples with subsequent CIN2+, 30.5% predominately contained microbiopsies/hyperchromatic crowded cell groups (HCGs), 27.3% sparse dyskarytotic cells, 4.2% pale cell dyskaryosis, 6.3% small dyskaryotic cells; 3.2% were misinterpreted cells, 8.4% contained other distracting cells, 7.4% were low contrast, 5.3% were unexplained and 7.4% were true negatives. The mean number of microbiopsies/HCGs in that category was 4.6. The mean number of abnormal cells in the sparse dyskaryotic cell category was 13.8. CONCLUSIONS: Microbiopsies/HCGs were the commonest reason for false negatives. They were usually present in sufficient numbers to be detected but interpretation could be problematic. Dispersed single abnormal cells were usually not identified because of their scarcity or the presence of distracters.

Outcome of SurePath™ cervical samples reported as borderline nuclear change by cytological subtype and high-risk HPV status.

BACKGROUND: The average borderline rate in cervical cytology samples for English laboratories was 3.8% with the range being 2.0-6.8% at the time of the present study, which was undertaken in order to determine the association between different subtypes of borderline nuclear change (BNC), high-grade cervical intraepithelial neoplasia (CIN) and high-risk human papillomavirus (hrHPV) status. MATERIALS AND METHODS: Of 68,551 SurePath(TM) cervical samples reported in one laboratory over a period of 2 years, 2335 (3.4%) were reported as BNC. hrHPV status was known in 1112 cases (47.6%). The outcome was known only for women with hrHPV-positive BNC, who were recommended for colposcopy under the National Health Service Cervical Screening Programme sentinel site protocol. Women with hrHPV-negative BNC were returned to 3-yearly recall. The cases were subdivided into BNC, high-grade dyskaryosis cannot be excluded (B-HG; 105 cases); BNC with koilocytosis (B-K; 421 cases); BNC with other features of HPV (B-HPV; 160 cases); and BNC, not otherwise specified (B-NOS; 426 cases) and were correlated with the histological outcome where available. RESULTS: The study population age ranged from 23 to 65 years. Cases that tested positive for hrHPV by Qiagen HCII assay comprised 78.1%, 81.0%, 73.1% and 67.8% of B-HG, B-K, B-HPV and B-NOS categories, respectively. CIN2 or worse (CIN2+) was found in 64.6%, 10.0%, 19.7% and 20.1% of hrHPV-positive cases of B-HG, B-K, B-HPV and B-NOS, respectively, which was significantly higher in the B-HG category (P < 0.001) and lower in the B-K category compared with B-NOS (p < 0.001) and B-HPV (p = 0.006) respectively. CIN3+ comprised 55.6%, 6.3%, 26.3% and 19.1% of biopsies in the same categories, respectively. CONCLUSIONS: Subtyping BNC is useful, especially B-K and B-HG, which, respectively, had the lowest and highest rates of detection of both CIN2+ and CIN3+, confirming that koilocytosis is likely to be associated with transient HPV infection. Women with B-HG should be referred to colposcopy in the absence of HPV triage.

Glandular neoplasia and borderline endocervical reporting rates before and after conversion to the SurePath(TM) liquid-based cytology (LBC) system.

Reporting rates for glandular neoplasia in 464,754 cervical samples reported at six laboratories in 12-month periods before and after the implementation of Surepath™ LBC processing are compared. The introduction of LBC processing is seen to have resulted in a significant (P = 0.001) increase in the detection rate for endocervical glandular neoplasia (from 2.2 per 10,000 tests to 3.9 per 10,000) while maintaining high levels of reporting specificity. An observed fall in the number of samples reported as showing borderline glandular neoplasia falls short of statistical significance, and the reporting of possible endometrial and 'other' glandular abnormalities appears to be unaffected. The underlying reasons for the observed improvement in detection of endocervical glandular neoplasia are discussed.

Accuracy and perceptions of virtual microscopy compared with glass slide microscopy in cervical cytology.

OBJECTIVE: To evaluate virtual microscopy in terms of diagnostic performance and acceptability among practising cytologists. METHODS: Twenty-four experienced cytologists were recruited to examine 20 SurePath® cervical cytology slides by virtual microscopy. Diagnostic accuracy was compared with glass slide microscopy using an unbiased crossover experimental design. Responses were allocated a score of one for a correct identification of normal or abnormal (borderline/atypical changes in squamous or glandular cells or worse) and a score of zero for an incorrect response (a normal slide reported as abnormal or vice versa). Perceptions of virtual microscopy were assessed by questionnaire analysis. RESULTS: Participants yielded a total of 285 responses for the virtual slide set and 300 for the glass slide set. The approximate time to screen a virtual slide was 18 minutes, compared with 8 minutes or less for a glass slide. Overall there was no significant difference between virtual microscopy and glass slide microscopy in terms of diagnostic accuracy (P = 0.22). Virtual microscopy under-performed when images were captured over a narrow focal range (P = 0.01). Diagnostic accuracy of virtual microscopy equalled that of glass slide microscopy when participants were able to focus through the full thickness of the slide images (P = 0.07). The most common difficulties experienced by participants with virtual microscopy were freezing of the computer screen during image download, slow response of the computer during slide movement and, in some instances, 'fuzzy' images. Cytologists have a strong preference for glass slides over virtual microscopy despite the overall equal diagnostic performance of the two viewing modalities. CONCLUSIONS: Diagnostic accuracy of virtual microscopy can equal that of glass slide microscopy. However, without good computer network connections, wide focal range and software that permits effortless navigation across virtual slides, cytologists are unlikely to be convinced of the utility of this technology for cytology screening and diagnosis.

The multidisciplinary colposcopy meeting: recommendations for future service provision and an analysis of clinical decision making.

OBJECTIVE: In 2004 the NHS Cervical Screening Programme (NHSCSP) recommended that multidisciplinary meetings should be incorporated into patient management. No data has been provided since then regarding its functionality or benefits. We aim to address this issue. DESIGN: Retrospective review. SETTING: Jessop Wing colposcopy multidisciplinary meeting (MDM), Sheffield, UK. POPULATION: All women referred to the MDM from September 2003 to September 2009. METHODS: Retrospective review of the colposcopy database (Sept 2003-Sept 2009), cross-referenced with multidisciplinary team (MDT) letters, patient notes and the hospital results reporting system. Baseline statistics were used for data analysis. MAIN OUTCOME MEASURES: Indications for MDT referral; concordance rates from cytopathology and histopathology review; concordance rates between MDT treatment decisions and final patient management. RESULTS: A total of 535 cases were discussed at 62 MDT meetings during the allocated study period. Discrepancy between referral cytology and cervix punch biopsy was the most common referral (49%). Cytology and histology review concurred with the initial reports in 75.8 and 97.8% of cases, respectively; the MDT decision was concordant with the final patient management in 97% of cases. The main reason for discordance (67%) resulted from patient factors. CONCLUSIONS: When significant discrepancies exist between colposcopy, cytology and histopathology, then MDT discussion seems pertinent as MDT discussion can lead to the avoidance of over-treatment. To improve timeliness of treatment, MDT meetings should occur at least monthly. The results of each case discussion should be recorded in the patient case notes, the minutes of each meeting should be circulated to all MDT members and a letter describing MDT recommendations must be sent to the colposcopist responsible for patient care.

The revised BSCC terminology for abnormal cervical cytology.

The BSCC terminology was originally published in 1986 and although highly successful, requires revision. Through a process of professional consensus and literature review this has been undertaken by the BSCC. The revision takes account of recent developments and improvements in understanding of morphology and disease process and is compatible with other terminologies in use elsewhere, whilst still maintaining a focus on practice in the UK cervical screening programmes.

Rapid (partial) prescreening of cervical smears: the quality control method of choice?

Rapid rescreening of all negative and inadequate smears is the quality control method of choice in the UK. The sensitivity of primary screening of laboratory and individual screeners are major indicators of screening quality and are dependent on the number of false negative smears found by rapid screening for their calculation. High sensitivity may indicate good quality primary screening or poor quality rapid review. Quantifiably high quality rapid rescreening is essential if these sensitivity figures are to be meaningful. A 12-month study was undertaken in routine practice using the prescreening mode to ascertain the sensitivity of rapid (partial) screening in our department. The final results of smears were compared with those of rapid prescreening. The calculated sensitivity ranged from 92-54% for high-grade abnormalities and 75-33% for all grades, revealing a wide range of performance between individual prescreeners. Rapid prescreening can identify individuals best suited to rapid screening in routine practice. By using these prescreeners only, the sensitivity of cervical screening could be raised. Rapid (partial) prescreening should be considered as the quality control method of choice.

Rapid screening: a comparative study.

Although rapid screening of negative and inadequate cervical smears is a quality assurance requirement for all UK laboratories, there has been little attempt to standardize the method and laboratories make use of a number of different techniques and times. The aim of this study was to assess the sensitivity of these various techniques by measuring their ability to pick out known false-negative smears. Completed questionnaires from 123 laboratories across England revealed that 52% of laboratories use a "step" technique, 19% use "turret", 15% use random paths and 34% attempt to rescreen the whole slide quickly. Twenty-two percent of laboratories use a mixture of techniques. Timings are also variable, with the majority of laboratories allowing screeners to review slides at a pace decided by themselves but usually between 1 and 2 min. The study involved 120 participants who performed a total of 24 000 rapid screens. The results showed that, of the 90 abnormal slides used in the study, 62 cases (69%) were identified as abnormal or needing review by more than 50% of participants. Overall rapid screening picked out 58% of high-grade squamous abnormalities, 59% of low-grade abnormalities and 72% of glandular lesions. Step screening performed best, followed by whole slide/random and then turret. One minute was the optimum time and there was a significant fall in performance once individuals attempted to rescreen large numbers (>50). The most significant finding was the marked variation in the performance of individuals using the same slide sets.

Rapid rescreen: a viable alternative to 1:10?

A rapid screen of those Pap smears designated as within normal limits is a quality control requirement of all UK laboratories. However in the United States standard QC involves a combination of 1:10 and selective rescreening procedures. Forty participants at the joint ASCT/ACP meeting in Las Vegas rapid screened 50 slides as part of a rapid screening workshop. They used different patterns of screening but were allowed only 60 seconds for each slide. Thirty of the slides contained abnormal cells but all had originally been called negative or unsatisfactory and as such were "false negatives". Ability to identify the abnormal smears varied considerably between individuals but overall rapid screening correctly identified 54% of the ascus or LGSIL cases and 61% of the HGSIL cases. The results demonstrate the superiority of such a rapid screen over 1:10 and question what if any role this outdated practice should have.