Importância do diagnóstico precoce da Chlamydia trachomatis / Importance of early diagnosis of Chlamydia trachomatis

A OMS estima que mais de 1 milhão de infecções sexualmente transmissíveis é adquirido todos os dias em todo o mundo. Dentre as ISTs, a clamídia é a principal causa da doença inflamatória pélvica e de infertilidade em mulheres em todo o mundo. Para esta pesquisa foi realizada uma revisão sistemática. O processo de revisão foi realizado através de uma busca na base de dados eletrônica, como PubMed, Scielo, Google Acadêmico, e em livros didáticos, utilizando os descritores infertilidade, IST, Chlamydia trachomatis. O objetivo deste estudo é buscar na literatura estudos que relatam a relação da Chlamydia trachomatis (CT) com problemas de infertilidade e os melhores métodos de diagnósticos e custo/benefício. O estudo concluiu que a CT é uma IST bastante prevalente no mundo e preocupante devido às complicações que muitas vezes são irreversíveis, como a infertilidade. Dentre os testes existentes no mercado, a PCR e a captura híbrida foram os que apresentaram melhor sensibilidade e especificidade.

The WHO estimates that more than 1 million sexually transmitted infections are acquired every day worldwide. Among STIs, chlamydia is the main cause of pelvic inflammatory disease and infertility in women worldwide. For this research a systematic review was carried out. The review process was carried out through a search in the electronic database, such as Pubmed, Scielo, Google Scholar and in textbooks, using the descriptors infertility, IST, Chlamydia trachomatis. The aim of this study is to search the literature for studies that report the relationship between CT and infertility problems and the best diagnostic methods and cost benefit. The study concludes that CT is an STI that is quite prevalent in the world and worrisome due to complications that are often irreversible such as infertility. Among the tests on the market, PCR and hybrid capture showed the best sensitivity and specificity.

Controle da qualidade em Citopatologia: A importância da fase pré-analítica / Quality control in Cytopathology: The importance of the pre-analytical phase

O exame citopatológico tem sido utilizado para rastreamento de câncer desde a década de 1940. O exame apresenta uma variação grande com relação à sensibilidade devido a vários fatores provocados durante o processo da fase pré-analítica. O estudo se baseia em uma revisão sistemática, onde os autores fizeram uma investigação sobre o tema, com a finalidade de identificar, selecionar, avaliar e sintetizar as evidências relevantes disponí- veis. A busca dos artigos científicos foi realizada por meio de buscas nas bases de dados eletrônica Literatura Latino-Americana em Ciência e Saúde (LILACS), Scientific Electronic Library Online (SCIELO), National Library of Medicine, Estados Unidos (MEDLINE). O objetivo deste estudo foi levantar os principais pontos da fase pré-analitica que podem impactar no resultado do exame de citopatologia e identificar os impactos gerados pela negligência do controle de qualidade analítico e as consequências geradas. Ao estudar a fase pré-analítica na citologia oncótica, entende-se a relevância da qualidade inicial, para o melhor resultado ao paciente. Todos os sistemas de avaliação de desempenho em laboratórios de citopatologia coincidem na necessidade de um programa de controle interno da qualidade perfeitamente estabelecido e executado, podendo obter resultados mais confiáveis.

The cytopathological exam has been used for cancer screening since the 1940s. The exam has a wide variation in sensitivity due to several factors caused during the process of the pre-analytical phase. The study is based on a systematic review, where the authors conducted an investigation on the topic, with the purpose of identifying, selecting, evaluating and synthesizing the relevant evidence available. The search for scientific articles was carried out by searching the electronic databases Latin American Literature on Science and Health (LILACS), Scientific Electronic Library Online (SCIELO), National Library of Medicine, States States (MEDLINE). The objective of this study was to raise the main points of the pre-analytical phase that can impact the result of the cytopathology exam and to identify the impacts generated by the neglect of the analytical quality control and the consequences generated. When studying the pre-analytical phase in oncotic cytology, the relevance of the initial quality is understood, for the best result to the patient. All performance evaluation systems in cytopathology laboratories coincide with the need for a perfectly established and executed internal quality control program, which can obtain more reliable results.

Expressão imuno-histoquímica dos biomarcadores p16 e Ki-67 na lesão intraepitelial cervical de alto grau: revisão de estudos / Immunohistochemical expression of biomarkers p16 and Ki-67 in high-grade cervical intraepithelial lesion: review of studies

O câncer do colo do útero é o quarto tumor mais comum entre mulheres no mundo e o terceiro no Brasil. A detecção precoce e a identificação das lesões cervicais são essenciais no rastreamento do câncer cervical. Nos últimos anos, vários marcadores têm sido apresentados como possíveis candidatos para a triagem eficiente de exames citológicos com anormalidades das células epiteliais. O objetivo deste trabalho é analisar a correlação com a expressão imuno-histoquimica dos biomarcadores p16 e Ki-67 com lesão intraepitelial cervical de alto grau na detecção molecular DNA/HPV de alto risco. A metodologia de pesquisa empregada é uma revisão sistemática, realizada por meio de buscas nas bases de dados eletrônica Literatura Latino-Americana em Ciência e Saúde (LILACS), Scientific Electronic Library Online (SCIELO), National Library of Medicine (MEDLINE) de artigos publicados no período de 2005 a 2019 nos idiomas português, inglês e espanhol. Concluiu-se que o uso das proteínas p16 e Ki67 auxilia na identificação das mudanças que acontecem durante a progressão da lesão cervical, aprimorando os métodos de rastreio atuais. O gene p53, a pRb e ciclinas também têm um papel crítico na carcinogênese e, desta maneira, também têm sido indicados para entrar nos painéis de estudo.

Cervical cancer is the fourth most common tumor among women in the world and the third in Brazil. Early detection and identification of cervical lesions are essential in screening for cervical cancer. In recent years, several markers have been presented as possible candidates for efficient screening of cytological exams with abnormalities of epithelial cells. The objective of this work is to analyze the correlation with the immunohistochemical expression of the biomarkers p16 and ki-67 with high-grade cervical intraepithelial lesion in high-risk DNA / HPV molecular detection. The research methodology employed is a systematic review, carried out by searching the electronic databases Latin American Literature in Science and Health (LILACS), Scientific Electronic Library Online (SCIELO), National Library of Medicine (MEDLINE) of published articles from 2005 to 2019 in Portuguese, English and Spanish. It was concluded that the use of proteins p16 and Ki67, help to identify the changes that happen during the progression of the cervical lesion, improving the current screening methods. The p53 gene, the retinoblastoma protein ­ pRb and cyclins also plays a critical role in carcinogenesis and thus, they have also been indicated to enter the study panels.

Performance of 3 methods for quality control for gynecologic cytology diagnoses.

OBJECTIVE: To evaluate performance and viability of internal quality control (QC) strategies in a public health laboratory of the state of São Paulo. STUDY DESIGN: A retrospective study was performed with 3 QC strategies to improve internal cytologic diagnoses: morphologic guided-list criteria (MGLC), 100% rapid-rescreening (100% RR) of negative slides ("turret" method) and 10% rescreening (10% R) of negative slides. Cases were examined at Adolfo Lutz Institute, São Paulo, Brazil, from 2002 to 2004. Histopathologic results, when available, were considered gold standard; cytologic consensus diagnosis was by 2 pathologists when histologic results were unavailable. RESULTS: MGLC selected 20.7% samples with cytologic atypias, 10% R selected 0.6% and RR selected 2.5%. Cytologic/histologic initial concordance was 57.4%, low-grade squamous intra-epithelial lesion false negative rate was 34.9% and high-grade squamous intraepithelial lesion false negative rate was 12.2%. After diagnosis, consensus concordance was 97.2%. CONCLUSION: The 100% RR and 10% R QC strategies detected more false negative cases in liquid-based cytology than in conventional Pap smears. The 100% RR strategy reduced the false negative results and allowed evaluation of individual staff performance. The 10% R strategy did not offer significant results. We concluded that association of MGLC and 100% RR strategies might improve cytologic diagnostic quality.

Whole, Turret and step methods of rapid rescreening: is there any difference in performance?

We compared the performance of the Whole, Turret and Step techniques of 100% rapid rescreening (RR) in detection of false-negatives in cervical cytology. We tested RR performance with cytologists trained and among those without training. We revised 1,000 consecutive slides from women participating in an ongoing international screening trial. Two teams of experienced cytologists performed the RR techniques: one trained in RR procedures and the other not trained. The sensitivities in the trained group were Whole 46.6%, Turret 47.4% and Step 50.9%; and in the non-trained group were 38.6, 31.6 and 47.4%, respectively. The kappa coefficient showed a weak agreement between the two groups of cytologists and between the three RR techniques. The RR techniques are more valuable if used by trained cytologists. In the trained group, we did not observe significant differences between the RR techniques used, whereas in the non-trained group, the Step technique had the best sensitivity.

Uterine cytopathology in a public health laboratory: impact from 20 years data (1984-2003)

O objetivo deste estudo foi identificar a distribuição dos diagnósticos citológicos pelo método de Papanicolaou das lesões pré neoplásicas e neoplásicas nos diferentes grupos etários no período de 20 anos. Foram utilizados dados retrospectivos dos diagnósticos citológicos cérvico-vaginais realizados no período de 1984 a 2003 no Setor de Citologia Oncótica. A distribuição dos diagnósticos de 1.020.853 amostras citológicas foi analisada por faixa etária em quatro intervalos de 5 anos (4 quinqüênios). Das amostras analisadas, 27.314 (2,68%) casos foram inadequados, 980.985 (96,09%) foram negativos e 12.554(1,23%) lesões intraepiteliais e câncer. Neste período, o pico de LSIL foi observado entre a faixa etária dos 20-24 de idade, HSIL foi mais freqüente no intervalo entre 30-34 anos de idade, e SCC/ADENO Ca foram acima dos 50 anos de idade. Nas mulheres entre 15-19 anos de idade foi observado acentuado aumento na freqüência de LSIL nos quatro qüinqüênios, de 66 (9,19%) no primeiro, 109 (9,83%) no segundo, 441(17,46%) no terceiro e 467 (15,97%) no último. A qualidade dos programas de prevenção de câncer de colo uterino pode ser medido pela freqüência das lesões do tipo LSIL. Os resultados do presente estudo são concordantes com os de outros programas contínuos e importantes para evitar a mortalidade em virtude dessas lesões.

Pero Vaz de Caminha: an-interchange program for quality control between Brazil and Portugal.

OBJECTIVE: To start an interexchange program for quality control in cervical cytology and discuss conceptual criteria for diagnosis. STUDY DESIGN: Slides were selected in the archives of the 2 institutes and included cases with unsatisfactory, negative and positive results. Sets of slides were changed between the partners every 3 months. At the end of each year a senior cytopathologist was invited to discuss the major discrepancies found in the study. RESULTS: A total of 1,041 cases were analyzed. Full concordance was obtained in 74.4% (774) of cases and discrepancies in 25.6% (267 cases). Full agreement was achieved in 276 (39%) of 707 cases categorized as negative. In 421 negative cases from laboratory A, this concordance represents 65.5% and 96.5% for laboratory B, which submitted 286 negative cases. The main discordance was the high number of atypical squamous cells of undetermined significance cases: 3.1% for A and 128 (33.2%) for B. Samples with discrepancies related to the quality of the material was another controversial issue: of 16 cases from laboratory A, 6 (37.5%) unsatisfactory cases were the same and 10 (62.5%) different. Laboratory B presented 20 unsatisfactory cases, and 14 (70.0%) had other diagnoses. Low grade squamous intraepithelial lesion and high grade squamous intraepithelial lesion concordance ranged from 75% to 80%, and invasive carcinoma has 4 discordances (28.5%), 3 previously screened as high grade squamous intraepithelial lesion and 1 as atypical squamous cells of undetermined significance. The kappa value obtained was 0.65, indicating substantial agreement. CONCLUSION: Our results indicated that atypical squamous cells of undetermined significance diagnoses are the crucial point of controversies and concern the quality of routine diagnosis in cytopathology.

Screening for cervical cancer in high-risk populations: DNA pap test or Hybrid Capture II test alone?

This study was designed to evaluate whether Hybrid Capture II (HC2) test alone refer women to colposcopy as appropriately as DNA Papanicolaou (Pap) test, in the context of a high-risk group of women using the recently validated DNACitoliq LBC system. Women with suspected cervical disease were included in this cross-sectional study at a tertiary center in São Paulo, Brazil, for further workup. All women had cervical material collected for LBC and HC2 for high-risk human papillomavirus (hrHPV)-DNA test. Irrespective of cytology and HC2 results, colposcopy, and cervical biopsy when applicable, was systematically performed. All tests were performed blindly. Sensitivity, specificity, positive and negative predictive values, and overall accuracy of both methods were computed in relation to histology. A total of 1,080 women were included: 36.4% (393/1080) had ACUS+, 10.2% (110/1080) were high-grade squamous intraepithelial lesions (HSIL) or cancer. Mean age was 33.5 years. All women underwent colposcopy, and cervical biopsies were performed in 38.4% (415/1080): 33% (137/415) of the biopsies were negative, 14.4% (155/415) were low-grade squamous intraepithelial lesions (LSIL), 10.7% (116/415) were HSIL, and 0.6% (7/415) were cancer. HC2 sensitivity to diagnose biopsy-proven HSIL was 100%. Because all HSIL cases had a positive HC2 test, sensitivity could not be improved by adding LBC. Specificity and positive and negative predictive values of DNA Pap were not significantly different from HC2 test alone when considering LSIL+ histology as "gold standard" and HSIL+ histology. As a screening strategy for women with high-risk for cervical cancer, DNA Pap test does not seem to add substantially to HC2 alone in terms of appropriately referring to colposcopy.

Desempenho das estratégias de controle de qualidade em diagnóstico citopatológico em laboratório de referência / Performance of quality control strategies in citopathological diagnosis in a reference laboratory

O câncer do colo do útero representa a 3° neoplasia maligna mais comum na população feminina no Brasil, superado apenas pelo câncer de mama e pele. O exame preventivo de Papanicolaou é reconhecido como um teste seguro e eficiente para o reconhecimento de alterações precoces do carcinoma do colo do útero. Neste estudo avaliamos três metodologias de controle de qualidade (CQ) interno de diagnóstico citológico: 1) realizada a partir de uma lista de critérios de seleção para revisão (LCSR); 2) revisão rápida (RR); 3) revisão de 10%. O objetivo deste estudo foi avaliar o desempenho e a viabilidade das estratégias de CQ interno em um laboratório de Saúde Pública de São Paulo. As amostras cérvico-vaginais foram recebidas pelo Instituto Adolfo Lutz, no período de 2002 a 2004. Das 4184 amostras, 1117 passaram pela revisão a partir LCSR e com o restante foram realizadas revisão de 10% e RR. A RR foi processada por dois profissionais treinados, adotando o método turret para o re-escrutínio, por 60 segundos. O padrão-ouro foi o exame histopatológico e nos casos em que não havia biópsia, utilizou-se o diagnóstico de consenso entre dois patologistas. Na revisão LCSR, 20,7% das amostras apresentaram lesão, na revisão de 10% foram 6,0% e na RR 2,5%. O índice kappa entre os dois observadores na RR foi kw= 0,98. A citologia de base líqüida apresentou um melhor desempenho quando comparado com a citologia convencional. A concordância diagnóstica do diagnóstico inicial com a biópsia foi de 57,4% com taxa de falso-negativo (FN) para LIEBG de 34,9% e para LIEAG 12,2% e a concordância do diagnóstico final foi de 97,2%. Concluímos que para a otimização do CQ interno de diagnóstico citológico será interessante um sistema que contemple a associação de mais de uma metodologia, com um protocolo de trabalho onde todas as não conformidades possam ser avaliadas para que se elaborem as possíveis ações corretivas. A RR parece contribuir para a redução das taxas de FN dos exames citológicos, p...

Desempenho das estratégias de controle de qualidade em diagnóstico citopatológico em laboratório de referência

O câncer do colo do útero representa a 3° neoplasia maligna mais comum na população feminina no Brasil, superado apenas pelo câncer de mama e pele. O exame preventivo de Papanicolaou é reconhecido como um teste seguro e eficiente para o reconhecimento de alterações precoces do carcinoma do colo do útero. Neste estudo avaliamos três metodologias de controle de qualidade (CQ) interno de diagnóstico citológico: 1) realizada a partir de uma lista de critérios de seleção para revisão (LCSR); 2) revisão rápida (RR); 3) revisão de 10%. O objetivo deste estudo foi avaliar o desempenho e a viabilidade das estratégias de CQ interno em um laboratório de Saúde Pública de São Paulo. As amostras cérvico-vaginais foram recebidas pelo Instituto Adolfo Lutz, no período de 2002 a 2004. Das 4184 amostras, 1117 passaram pela revisão a partir LCSR e com o restante foram realizadas revisão de 10% e RR. A RR foi processada por dois profissionais treinados, adotando o método turret para o re-escrutínio, por 60 segundos. O padrão-ouro foi o exame histopatológico e nos casos em que não havia biópsia, utilizou-se o diagnóstico de consenso entre dois patologistas. Na revisão LCSR, 20,7% das amostras apresentaram lesão, na revisão de 10% foram 6,0% e na RR 2,5%. O índice kappa entre os dois observadores na RR foi kw= 0,98. A citologia de base líqüida apresentou um melhor desempenho quando comparado com a citologia convencional. A concordância diagnóstica do diagnóstico inicial com a biópsia foi de 57,4% com taxa de falso-negativo (FN) para LIEBG de 34,9% e para LIEAG 12,2% e a concordância do diagnóstico final foi de 97,2%. Concluímos que para a otimização do CQ interno de diagnóstico citológico será interessante um sistema que contemple a associação de mais de uma metodologia, com um protocolo de trabalho onde todas as não conformidades possam ser avaliadas para que se elaborem as possíveis ações corretivas. A RR parece contribuir para a redução das taxas de FN dos exames citológicos,...

Molecular strategies for identifying human papillomavirus infection in routinely processed samples: focus on paraffin sections.

OBJECTIVE: To optimize the protocols of human papillomavirus (HPV) detection in clinical samples, we used polymerase chain reaction (PCR)-based techniques in paraffin-embedded tissue sections and compared the results with those obtained with PCR and Hybrid Capture II (HC2) performed in liquid-based cytology (LBC) preservation medium. MATERIALS AND METHODS: Forty-five consecutive cervical biopsy specimens were taken from women participating in the ongoing Latin American Screening Study at Leonor Mendes de Barros Hospital, São Paulo, Brazil, during 2003 and 2004. The biopsy specimens were analyzed for HPV by a modified GP5+/GP6+ PCR protocol, and the results were compared with those obtained by PGMY PCR and HC2 in samples collected in LBC preservation medium. RESULTS: beta-Globin was detected in 100% of the multiplex PCR system from LBC samples and 66.7% with PCO4+/PCO3+ PCR in biopsy specimens. Of the three methods, PGMY PCR system and HC2 were equally effective in detecting HPV; both detected 13 cases in 45 samples (28.9%). The GP5+/GP6+ PCR applied in biopsy specimens showed a 20% HPV detection rate (9/45). CONCLUSIONS: Our PCR protocols worked reasonably well and allowed us to compare the three molecular methods with histological and cytological findings. The reproducibility of the results makes the technique applicable in archival materials.

DCS liquid-based system is more effective than conventional smears to diagnosis of cervical lesions: study in high-risk population with biopsy-based confirmation.

OBJECTIVE: To compare the performances of Papanicolaou test (PapTest) and of a new liquid-based cytology method, DNA-Citoliq System (DCS), in a high-risk population, with histology confirmation. METHODS: Paired specimens of exfoliated cervical cells were collected under split-sample protocol. All patients were submitted to colposcopy and a biopsy taken when any atypical transformation zone was seen. Sensitivity, specificity, positive and negative predictive values, and overall accuracy of both conventional and DCS methods were computed in relation to histology. RESULTS: A total of 1095 patients were analyzed by two cytology methods and, in 425 (38.8%), histologically. There were significantly more adequate samples with DCS (98.63%) than with conventional (89.6%) smears (P < 0.001). ASCUS was diagnosed significantly more with DCS than with conventional Pap (P < 0.001). Conventional Pap misclassified as normal 55.4% (158/285) of cases with either LSIL or HSIL or cancer at histology, whereas DCS misclassified 31.2% (89/285) of cases (P < 0.001). DCS had a significantly higher sensitivity (70% and 91.3%) than the conventional Pap (49.8% and 72.8%) to detect both LSIL+ and HSIL+ at histology, respectively. On the other hand, specificity of conventional smear (88.2% and 85.2%) was significantly higher than DCS (75.4% and 70.9%) considering both LSIL+ and HSIL+ at histology, respectively. CONCLUSIONS: This study confirms the superiority of the liquid-based cytology system DCS to detect cervical lesions. The rate of adequate DSC slides was significantly higher than with conventional cytology.

Immunocytochemical expression of p16INK4A and Ki-67 in cytologically negative and equivocal pap smears positive for oncogenic human papillomavirus.

This study was designed to analyze the cross-sectional comparison of the p16 and Ki-67 immunocytochemical expression in negative and equivocal (atypical squamous cells of undetermined significance (ASC-US)) liquid-based cytology (LBC) samples testing positive for high-risk human papillomavirus (HPV) types with HC2 assay or polymerase-chain reaction (PCR). A series of 199 consecutive LBC specimens derived from the same number of women participating in the ongoing Latin American Screening Study at Leonor Mendes de Barros Hospital, Sao Paulo, were analyzed using immunocytochemistry for expression of p16 and Ki-67 in negative and equivocal LBC samples testing positive for high-risk HPV types with hybrid capture II test (HC2) or PCR. All patients with at least one test positive (cytology, PCR, and/or HC2) were followed each 6 months for 3 years. The follow-up procedure consisted of visual examination, colposcopic inspection, cytology, and HC2 assay. Among the negative cytologic samples, 101 were HPV-positive and 55 HPV-negative. Of the HPV-positive group, 59 of 101 cases (58.4%) were positive for both p16 and Ki67 immunostaining, and 17 of 101 (16.8%) were negative for both. The proportion of Ki-67-positivity increased almost in parallel with the increasing grade of p16-positivity (p = 0.0001 for linear trend). In the HPV-negative group, both markers were negative in 41 of 55 cases (74.5%), and no statistical relationship was observed between the two markers (Pearson, p = 0.595). HPV-positive ASC-US samples demonstrated a simultaneous positive immunoreaction for p16 and Ki67 in 11 of 16 cases (68.7%), whereas 3 (18.7%) were concurrently negative. The relationship between the two markers was of borderline significance (Pearson, p = 0.053), but no linear relationship was found between the graded p16 and Ki-67 expression (p = 0.065 for linear trend). In the HPV-negative ASC-US group, there was no statistical association between the graded p16 and Ki-67 positivity (Pearson, p = 0.281). After 36 months of follow-up of the ASC-US patients, 6 women still displayed ASC-US smear, of which 4 of 6 were HPV-positive and expressed both p16 and Ki-67 markers. Two of 43 ASC-US smears had high-grade squamous intraepithelial lesions diagnosed (4.6%), and 1 had low-grade squamous intraepithelial lesion (2.3%). All of those were positive for HPV, p16 and Ki-67. Patients with ASC-US diagnosis and positive high-risk HPV status and positive for p16 Ki67 should be carefully observed to exclude occurrence of a squamous intraepithelial lesion. The combination of these two markers can be a useful implement for management of women with equivocal cytology.

100% rapid rescreening for quality assurance in a quality control program in a public health cytologic laboratory.

OBJECTIVE: To verij5 the efficacy of the quality control (QC) program in a cytologic laboratwy with a rapid rescreening (RR) protocol. STUDY DESIGN: RR, according to the Turret RR method, of all samples initially screened as negative at the Laboratory of Cytology, Adolfo Lutz Institute, was performed. The slides were reviewed for 60 seconds. Suspect smears were fully checked by 2 reviewers to determine the final diagnoses. A total of 2954 sequential cytologic results were considered in this study. Of the 2954, 2568 (86.9%) were considered initially negative according to our internal QC, and these cases underwent RR. Also, 10% were randomly selected from these negative cases for full reviewing. The internal QC in our laboratory includes review of cases selected according to clinical and cytomorphologic criteria. RESULTS: Among the 2954 total cases, QC detected 386 (13%) atypias with final diagnoses reported according to The Bethesda System 2001 as follows: 82 (2.18%) low grade squamous intraepithelial lesions (LSILs), 35 (1.18%) high grade squamous intraepithelial lesions (HSILs), 2 (0.06%) squamous cell carcinomas, 105 (3.5%) atypical cells of undetermined significance (ASC-US), 4 (0.12%) atypical endocervical cells (AECs) and 158 (5.3%) unsatisfactory samples. RR of 2568 smears initially considered negative selected 194 (7.5%) slides. Of the 194, 146 (75.3%) were negative, 28 (14.4%) ASC-US, 5 (2.6%) AEC, 1 (0.5%) LSIL and 14 (7.2%) unsatisfactory. Full review of a 10% random fraction of the 2568 cases interpreted as negative did not detect lesions but did detect 5 (1.95%) unsatisfactory samples. CONCLUSION: Internal QC used in our laboratory based on clinical and cytomorphologic criteria to select cases for review proved to be an efficient method of detecting HSIL and cervical cancer. The consensus basis of this program strongly limits the false positive and false negative rates and also provides subjects with continuing education. One hundred percent RR is more efficient than 10% full reviewing in detecting cervical abnormalities.

O impacto do diagnóstico citológico de atipias indeterminadas no sistema público de saúde / The impact of cytological diagnosis of undetermined atypias in public health system

Introdução: as alterações citológicas, de significado indeterminado representam uma importante limitação diagnóstica nos programas de escrutíneo de lesões cérvico-vaginais. A introdução de métodos biomoleculares, como o sistema de captura híbrida para detecção de HPV de alto risco contribui para a otimização da conduta clínica dessas pacientes, indicando colposcopia com precisão. Objetivo: avaliar o significado de lesões de significado indeterminado com relação à infecção pelo HPV, com o uso do teste de DNA para HPV com o método da captura de híbridos II. Métodos: foram estudadas amostras de 236 casos consecutivos examinados no laboratório da DIGENE-BRASIL, de pacientes com diagnóstico citológico prévio de ASCUS. As amostras foram submetidas ao teste de captura híbrida para identificação de DNA-HPV dc alto e baixo riscos. Resultados: dos 236 casos analisados, 183 (77,5 por cento) foram negativos para o teste de captura híbrida, seis (2,6 por cento) foram positivos para HPV de baixo risco e 47 (19,9 por cento) foram positivos para HPV de alto risco. Conclusão: as amostras positivas para HPV de baixo risco representam uma pequena e não-considerável minoria de casos, provavelmente, transientes. Cerca de 20 por cento dos casos foram positivos para HPV de alto risco e deverão ser encaminhados à colposcopia e biópsia, se necessário. Esses casos representam um grande potencial de progressão para lesões cervicais

Estudo preliminar do SISCOLO-Qualidade na rede de saúde pública de São Paulo / SISCOLO-quality control system in the health public laboratories: preliminary study

Analisar criticamente os primeiros resultados do Sistema de Informação Laboratorial do Programa Nacional de Combate ao Câncer de Colo Uterino (SISCOLO-Qualidade). Foram utilizados esfregaços cervicovaginais corados pelo método de Papanicolaou, provenientes da rotina diagnóstica do Laboratório de Anatomia Patológica da Fundação Oncocentro de São Paulo (FOSP) e referentes a março de 2000. Esses casos foram reavaliados em estudo cego pela equipe do Setor de Citologia Oncótica da Divisão de Patologia do Instituto Adolfo Lutz/São Paulo. O Programa SISCOLO-Qualidade seleciona, entre os casos analisados no período, todas as citologias positivas (ASCUS, AGUS, NIC e carcinomas) e, para completar 10 por cento do total das lâminas, todos os casos insatisfatórios e negativos aleatoriamente. Dos 8.370 casos da rotina da FOSP, o SISCOLO-Qualidade selecionou 837 amostras. Entre as amostras selecionadas, 23,4 por cento apresentaram material representativo da junção escamocolunar, 5 por cento foram considerados material insatisfatório e 71,1 por cento, material satisfatório, mas limitado. O resultado da análise foi 86,62 por cento de concordância, 12,42 por cento de discordância de um grau e 0,96 por cento de discordância de mais de um grau. Concluímos que o Programa SISCOLO-Qualidade é aplicável na rede de saúde pública para monitoramento externo, atendendo às expectativas de qualidade exigidas pelo Ministério da Saúde.

High-risk HPV detection by Hybrid Capture and ploidy determination by a computer-assisted system in cervical biopsies.

OBJECTIVE: To correlate high-risk HPV (hrHPV) detection by Hybrid Capture II (HC2) (Digene, Gaithersburg, Maryland, U.S.A.) with DNA content (ploidy) of cervical biopsies analyzed by a computer-assisted system. STUDY DESIGN: Cervical biopsies from 54 women examined at Leonor Mendes de Barros Hospital, São Paulo, as part of the Latin American Screening study during 2002--2003, were tested for hrHPV with HC2. All patients had been referred for colposcopic examination due to an abnormal cervical cytology. The final diagnosis included 30 cervicitis, 14 cervical intraepithelial neoplasia (CIN) 1, 5 CIN 2, 4 CIN 3 and 1 squamous cell carcinoma (SCC). Five-micrometer sections of each biopsy were stained with Feulgen-tionine and evaluated with the CAS 200 System (Becton Dickinson, U.S.A.), using the 3.0 software (version 8.1) of the DNA Quantitative Measurement Program (Becton Dickinson). Ploidy was evaluated from histograms obtained by analyzing atypical nuclei. RESULTS: Of the 30 cervicitis cases, 28 (93.3%) were diploid, and hrHPV was detected in 8 (28.5%) of the cases. Two tetraploid cervicitis lesions were observed, 1 positive and 1 negative for hrHPV. Among the CIN 1 lesions, 8 (57.1%) were diploid and 6 (42.8%) aneuploid. Of the latter, 4 (66.6%) were negative and 2 (33.3%) positive for hrHPV. Of the 5 CIN 2 lesions, 2 were diploid, 2 aneuploid and 1 tetraploid; all were positive for hrHPV. All CIN 3 lesions and the SCC proved to be aneuploid and positive for hrHPV. CONCLUSION: The data suggest that the majority of cervicitis and CIN 1 lesions are diploid and negativef or hrHPV. This is in sharp contrast to high grade CIN 2-3 lesions, all of which were positive for hrHPV in this study and also aneuploid, consistent with their progressive potential.

Pap test in a high-risk population comparison of conventional and liquid-base cytology.

Liquid-based cytology (LBC) is believed to have better sensitivity than conventional smears (CSs) and offers the possibility to perform molecular assay. The goal of this work was to study the performance of CS and LBC in a high-risk population and to compare the results with the hybrid capture (HC) II for high-risk human papillomavirus (HPV). Samples were collected from selected women with clinical suspicions of low genital tract lesion at Pérola Biygnton Hospital (São Paulo, Brazil). After CS preparation, the brush was introduced in the endocervix and a new sample was collected and rinsed in the preservative medium of the system. The residual material was used to HC2. From 925 cases, LBC was unsatisfactory in 4 (1.51%) cases and CS was unsatisfactory in 100 cases (10.81%); among theses cases HC2(+) reactions was observed in 54 (54%) CSs and 3 (21.4%) LBCs. Considering cases with atypia of undetermined significance (squamous and glandular), 85 (77.27%) cases from LBC and 44 (86.4%) from CS were positive for HC2 assay for high-risk DNA-HPV. The difference among the methods was not significant (P < 0.38). The diagnosis improvement of LBC in comparison with CS was 86% in satisfactory samples, 92.76% in undetermined atypical lesions (including glandular), 83% in positive low-grade squamous intraepithelial lesions (LSIL(+)), and 86.84% in high-grade SIL(+) (HSIL(+)). HC2(+) reactions were observed in 144 CS cases and 266 LBC cases with abnormalities. Our results have showed that LBC was superior to CS in a high-risk population to detect lesions with high concordance with HC2(+) reactions; CSs also exhibit a high concordance with HC2 assay but with inferior performance to detect lesions.

A morphological protocol and guide-list on uterine cervix cytology associated to Papillomavirus infection.

The present study was designed to further assess the validity of the cytological description of morphological lesions said to be related to Papillomavirus (HPV) infections in senior women. The casuistic comprised 196 cervical smears from a group of women with no clinical or morphological evidence of neoplasia, collected simultaneously with samples submitted to detection of HPV DNA by PCR in a previous study. Three experienced cytologists studied each slide in two different conditions, with an interval of 20 months between them. The first approach was performed under routine laboratory standards, whereas the second was guided by a list of 16 well-defined parameters indicative of HPV-related cytological lesions. When suspicious cases of HPV-related alterations were grouped with positive cases, they showed on average: sensitivity of 25.5%, specificity of 84.4% and positive predictive value (PPV) of 26.8%. When suspicious cases were grouped with negative cases, sensitivity decreased, whereas specificity and PPV increased, as expected. In the second reading, which followed a "guide-list", a decrease in sensitivity was observed, contrasting with a sharp increase of positive predictive value. Among the 16 cytomorphological criteria tested, "koilocytosis", "mild koilocytosis" and "condylomatous parabasal cells" yielded the best predictive value for HPV DNA detection by PCR. In conclusion, despite the low sensitivity, cytopathologic assessment of cervico-vaginal smears leads to a highly specific diagnosis of HPV infection in menopausal women, with PPV of 91.0% when directed by a guide-list of well-defined morphologic criteria.

Hybrid capture II and polymerase chain reaction for identifying HPV infections in samples collected in a new collection medium: a comparison.

OBJECTIVE: To compare the performance of human papillomavirus (HPV) DNA detection by polymerase chain reaction (PCR) and Hybrid Capture II (HCII) test (Digene, Gaithersburg, Maryland, U.S.A.) in residual cells left in the collection vials of the DNACitoliq system (Digene Brasil, São Paulo, Brazil). STUDY DESIGN: A series of 263 cervical samples collected for liquid-based cytology with the DNACitoliq system was tested for oncogenic HPV types first with HCII and subsequently with PCR. After DNA purification with GFX Genomic Blood DNA Purification Kit (Amersham, Piscataway, New Jersey, U.S.A.), PCR was performed using AmpliTaq Gold DNA polymerase (Applied Biosystems). PGMY09/11 L1 consensus primers and GH20/PCO4 primers for human beta-globin target were coamplified. RESULTS: Altogether, 260 samples were positive for beta-globin, and 3 negative ones were excluded from the analysis. PCR and HCII yielded concordant results in 199 cases (76.5%) (102 positive and 97 negative), with Cohen's kappa of .577 (95% CI .477-.677) and weighted kappa of .733 (95% CI .659-.791). HPV prevalence in different categories of cytologic abnormalities was practically identical with HCII and PCR assays (P=.989). Among the 61 (23.5%) discrepant cases, 28 samples were HCII+/PCR- cases. Of these, 27 of 28 samples showed a low viral load, and 1 had an intermediate viral load. CONCLUSION: The data suggest that residual material from the DNACitoliq system adequately preserves HPV DNA for detection by HCII and PCR, with performance similar to that of specimen transport medium.