Comparison of spatula and nonspatula methods for cervical sampling

A comparison between nonspatula (cotton swab and Cytobrush) cervical sampling methods and spatula (wooden Ayre spatula and plastic extended-tip Szalay Cyto-Spatula) sampling methods was made in 109 cases. Based on the presence of endocervical cells, there were statistically significant qualitative differences between the non-spatula methods as well as between the spatula methods, but not between the Cytobrush and Cyto-Spatula smears or the cotton swab and Ayre spatula smears. In all kinds of inflammatory lesions, the spatula samples were more accurate and diagnostic than the nonspatula ones. In all cases of cervical intraepithelial neoplasia and in most cases of squamous metaplasia, the Cyto-Spatula sample was the most accurate. It is concluded that the Szalay Cyto-Spatula method is superior to the other cervical sampling methods because it provides well-preserved cells from both the endocervix and the ectocervix in one smear. The Cytobrush should be used in conjunction with spatula sampling (combination method) for effective sampling of the cervix. The Cytobrush alone is effective mainly for endocervical sampling while the Ayre spatula alone is effective mainly for ectocervical sampling; the cotton swab is ineffective for both endocervical and ectocervical sampling.     

Use of the Cytobrush for cervical sampling after cryotherapy

The presence of endocervical cells in routine gynecologic smears (prepared from spatula and cotton swab samples) and Cytobrush smears was analyzed in 52 patients with a history of prior cryotherapy. These cases represented 11% of the 491 women evaluated using both techniques between August 1, 1987, and January 31, 1990. The routine smear contained endocervical cells in 25 (48%) of the 52 cases while the Cytobrush smear contained endocervical cells in 49 (94%) of the cases. The use of the Cytobrush for cervical cytologic screening thus appears to be of value in patients with a prior history of cryotherapy, which frequently renders the transformation zone less accessible to routine sampling.     

Comparative evaluation of seven cell collection devices for cervical smears

OBJECTIVE: To compare the most commonly used cervical sampling devices. STUDY DESIGN: We examined seven cytology sampling devices (Cytobrush, Cervex brush, Szalay spatula, Papex spatula, WrGKK spatula [main social security agency in Vienna], cotton swab and loop). Eight hundred smears were assessed for even distribution of cells, percentage of slide surface covered with cells, and presence and number of endocervical cells. RESULTS: Even distribution of cells was best with the WrGKK spatula. Percentage of slide surface covered with evaluable cells was best with the Cytobrush. Highest ranking for the presence of endocervical cells was found for the Cytobrush. Cotton swabs and loop showed inferior results in all categories. CONCLUSION: The use of cervical cell sampling devices showing the best cytologic results improves the interpretation and validity of cervical smears. Our results suggest that cotton swabs and loops should not be used for cervical cell sampling.     

Analysis of five sampling methods for the preparation of cervical smears

The quality of the cervical smear, a decisive factor in the efficacy of population screening, can depend on the sampling method utilized. An analysis was made of the performance of five sample takers in a screening program, each of whom had made approximately 5,000 smears, and of the five sampling methods each had used: spatula alone (method A), Cytobrush plus spatula (method B), Cytopick (method C), cotton swab plus spatula (method D) and Cervex brush (method E). The differences between the sample takers and the sampling methods were significant in both the detection of grade III cervical intraepithelial neoplasia (CIN III) (P less than .01) and in the production of smears containing endocervical cells (EC+) (P less than .018). The data obtained firmly establish the importance of the presence of endocervical cells for smear adequacy. The results of this study indicate that (1) method B (Cytobrush plus spatula) and method C (Cytopick) give superior results in the preparation of EC+ smears and in the detection of CIN III and thus should be used in population screening programs, and (2) methods A and D should not be used for cervical cytologic sampling in such programs.     

Relation between sampling device and detection of abnormality in cervical smears: a meta-analysis of randomised and quasi-randomised studies.

OBJECTIVE: To assess the diagnostic yield of different sampling devices used in cervical screening. DESIGN: Meta-analysis of randomised and quasi-randomised studies. SETTING: All randomised and quasi-randomised studies comparing the yield of cytological or histological abnormalities when two or more different sampling devices were used. SUBJECTS: 85,000 patients included in 29 studies reported in 28 papers. MAIN OUTCOME MEASURES: Pooled relative risk and 95% confidence interval of the yield of mild dysplasia or worse in smears recovered by each sampling method versus each other method with which it was compared; sensitivity or positive predictive value, or both, of cytological versus histological results in six studies from which sufficient data were available. RESULTS: There were no substantial differences in the yield of cytological abnormalities between the Ayre spatula, the Cytobrush, and the cotton swab used alone. There were also no substantial differences in the yield of cytological abnormalities between the extended tip spatula, the Ayre spatula combined with the Cytobrush or cotton swab, or the Cervex brush. The Ayre spatula, Cytobruah, or cotton swab used alone generally performed significantly worse than the combinations, the extended tip spatula, or the Cervex brush. There were no substantial differences in sensitivity or positive predictive value between the sampling methods. CONCLUSIONS: These results support the use of either the extended tip spatula, a combination of any spatula plus the Cytobrush or cotton swab, or the Cervex brush for cervical screening.     

Improved endocervical sampling with the Cytobrush.

OBJECTIVE: To evaluate the effectiveness of the Ayre wooden spatula, the cotton-tipped swab and the Zelsmyr Cytobrush in obtaining endocervical cells. DESIGN: Cross-sectional comparison study. SETTING: Family practice unit. PATIENTS: All postpubertal, nonpregnant women who underwent a routine Papanicolaou smear during a 7-month period. INTERVENTIONS: The three devices were used in each patient in a randomized sequence. An experienced cytotechnologist blinded to the device used evaluated the slides for overall epithelial cellularity (graded from 0 [acellular specimen] to 12 [overloaded sample]), density (the number of groups of five or more endocervical cells) and size of cell clusters (5 to 10 cells per cluster [score of 1], 11 to 100 [2] or more than 100 [3]). MAIN RESULTS: Samples from 2 of the 136 women were rejected because of improper labelling of the slides or failure to use all three devices. Seventy-six (57%) of the smears obtained with the spatula and 71 (53%) with the swab had no endocervical cells, as compared with only 14 (10%) obtained with the Cytobrush (p = 0.001). The overall cellularity (and standard deviation [SD]) of the smears obtained with the Cytobrush (5.69 [SD 1.17], p = 0.001) and the spatula (5.70 [SD 1.46], p = 0.001) was significantly greater than the cellularity of those obtained with the swab (4.31 [SD 1.17]). The Cytobrush yielded significantly more groups of endocervical cells (109.84 per slide) than either the spatula (4.17) or the swab (6.25) (p = 0.001). The Cytobrush also produced larger cell clusters (1.56 [SD 0.67], p = 0.001) than either the swab (0.83 [SD 1.70]) or the spatula (0.64 [SD 0.67]). CONCLUSIONS: The Cytobrush and the spatula should be used instead of the spatula alone or the spatula and the swab for collecting endocervical cells.     

Cervical smears following laser treatment. Comparison of Cervex brush versus Cytobrush-Ayre spatula sampling

For 802 women at initial follow-up after laser treatment of cervical lesions, 421 smears prepared using the Cervex brush were compared with 381 smears prepared using the combination of a Cytobrush plus an Ayre spatula. The smears were graded for adequacy, the presence of endocervical or metaplastic cells and the presence and degree of epithelial abnormalities. Endocervical or metaplastic cells were seen more often in Cytobrush-Ayre spatula smears (94.5%) as compared with Cervex brush smears (88.8%; P = .004). Also, the number of samples classed as inadequate was significantly greater with Cervex brush smears (4.0%) than with Cytobrush-Ayre spatula smears (0.3%; P = .0003). The number of smears showing dysplasia was too small to detect realistic differences between the two sampling methods. These findings suggest that, in women who have had laser treatment of the cervix, Cytobrush plus Ayre spatula sampling produces better-quality smears than does Cervex brush sampling, with regard to both adequacy and the presence of endocervical cells.     

Comparison of Cytobrush sampling, spatula sampling and combined Cytobrush-spatula sampling of the uterine cervix

Since the introduction of the Cytobrush for sampling the uterine cervix, some practitioners have ceased taking a concomitant cervical scraping using a spatula. To examine whether Cytobrush sampling alone is adequate for the diagnosis of cervical lesions, the Cytobrush and spatula samples in 444 smears (most with original diagnoses of at least mild dysplasia) were analyzed separately for the presence of diagnostic cells, endocervical cells and squamous cells. Of the 412 smears showing pathologic findings (mild to severe dysplasia or worse), diagnostic cells were present in 400 Cytobrush samples and in 369 spatula samples; the combination of both samples thus gave a 3% gain in correct diagnoses as compared to use of the Cytobrush samples alone. Another 18 smears would have been underdiagnosed based only on the Cytobrush samples. Endocervical cells were present in 95.3% of the Cytobrush samples and 83.8% of the spatula samples; squamous cells were present in 93.9% of the Cytobrush samples and 96.8% of the spatula samples. Analysis confirmed that it is important that the smear should contain both endocervical and squamous cells. A positive relationship between the absence of squamous cells in the Cytobrush sample and the probability of a false-negative assessment was suggested. It thus seems inadvisable to replace the combination sampling method by Cytobrush sampling alone, which may lead to a false-negative diagnosis.     

Cervex brush versus vaginal–cervical–endocervical (VCE) triple smear techniques in cervical sampling

Cervex brush versus vaginal–cervical–endocervical (VCE) triple smear techniques in cervical sampling
Cervex brush sampling was compared with the conventional triple vaginal–cervical–endocervical (VCE) smear technique. Nine hundred and fifty‐nine Cervex brush smears and 1064 VCE smears were studied. All smears with both methods were technically satisfactory for evaluation. Endocervical cells were found in 90.7% and metaplastic cells in 73.3% of Cervex brush samples and in 92.5% and 64.1% of VCE samples, respectively. There were significantly more metaplastic cells in smears from premenopausal women. Low grade squamous intraepithelial lesion (SIL) was found in three Cervex brush samples and in two VCE samples. High‐grade SIL was found only in one Cervex brush sample. Benign cellular changes were found in 142 Cervex brush samples and in 144 VCE samples. Sampling with the Cervex brush is efficient, simple and fast and gives high quality cervical smears for cytological evaluation.     

Cytobrush and wooden spatula for oral exfoliative cytology. A comparison.

The Cytobrush has been used frequently in cervical cytology, but as yet its value in oral exfoliative cytology has not been assessed. A study was undertaken to compare the efficiency of the Cytobrush with that of the wooden tongue spatula. For 26 patients, two smears were collected from clinically normal mucosa from four sites in the oral cavity (buccal mucosa, dorsal tongue, ventral tongue and hard palate). The smears were graded for cell yield and dispersion on a three-point scale. The results were analyzed using the chi 2 test. The Cytobrush was found to be significantly more efficient than the wooden spatula, in terms of both cell yield (P less than .005) and cell dispersion (P less than .005). When each site was examined separately, the Cytobrush produced significantly better dispersion for the dorsal tongue, ventral tongue and buccal mucosa and a better cell yield for the tongue surfaces. No significant difference for cell yield or dispersion was found for the hard palate. The study showed that the Cytobrush is an effective instrument for use in exfoliative cytology of normal oral mucosa.     

Collection devices for cervicovaginal cytology: a comparison

OBJECTIVE: To compare cervicovaginal smears obtained by a cotton-tipped swab with those obtained by cervix brush and modified Ayre spatula. STUDY DESIGN: A combined cervicovaginal smear was collected from 100 women using 3 different collection devices: cotton-tipped swab, cervix brush, and modified Ayre spatula. In each patient a set of 3 smears was collected by the same cytotechnologist using all 3 devices in random order. Smears were evaluated using parameters mandatory for an optimal smear: evenly dispersed, well-preserved, adequate cells from the transformation zone. The cost and availability of the collection devices were also considered. RESULTS: The swab was the most effective device in obtaining thin, evenly spread, adequate, well-preserved smears as against the cervix brush and Ayre spatula. The pickup of abnormal cells was similar with the cotton-tipped swab and cervix brush, while the Ayre spatula failed to yield high grade squamous intraepithelial lesions, atypical glandular cells of undetermined significance and adenocarcinoma cells. The cotton-tipped swab proved to be the most cost effective. CONCLUSION: A properly prepared cotton-tipped swab is an inexpensive, readily available, nontraumatic collection device that yields smear of optimal quality.     

Papanicolaou smears without endocervical cells. Are they inadequate?

The retrieval of columnar endocervical cells from the squamocolumnar junction has generally been considered to be a measure of the adequacy of a Papanicolaou smear; this implies that, if endocervical cells are absent from the smear, the examination for cervical cancer is less than optimal and should be repeated. A study was undertaken to determine if women with serial Papanicolaou smears without endocervical cells showed an increased rate of development of cervical atypia in subsequent smears. The smears of 18,914 women were evaluated for the presence or absence of endocervical cells and for the subsequent development of an abnormal smear over a four-year study period. No differences were found in the rates of atypia between women with and those without endocervical cells on serial Papanicolaou smears. Women with prior Papanicolaou smears without endocervical cells were much more likely to have a subsequent Papanicolaou smear without endocervical cells. Although no difference was found in the incidence of cervical atypia in the two groups during this short study period, these results should be considered to be preliminary.     

Relationship between the diagnosis of epithelial abnormalities and the composition of cervical smears

The significance of endocervical columnar cells as a high-quality parameter of cervical smears was studied. In a cohort of women with two successive screenings, the consistency of the cellular composition of the cervical smears and the relation between the cellular composition of the smears and the frequency of the diagnosis of abnormal epithelial changes was investigated. At the first screening, a significantly higher number of epithelial abnormalities was found in smears with endocervical columnar cells than in smears without endocervical columnar cells. A significantly higher number of abnormal epithelial changes was found on the second screening in smears from women whose smears from the first screening did not contain endocervical columnar cells than in smears from women whose smears from the first screening did contain endocervical columnar cells. The presence of endocervical cells should be considered a very important indicator of the quality of cervical smears. The chance of missing an abnormal epithelial change is increased in smears without endocervical columnar cells. When endocervical columnar cells are absent, the smear should be considered to be of unreliable quality and a repeat smear should be taken after a short interval, unless the absence of columnar cells can be satisfactorily explained.     

Quality grading for cervical smears

Three thousand five hundred and eighty cervical smears were taken in 1990–1992 at a Genitourinary Medicine Clinic with various spatula or spatula brush combinations. the unsatisfactory rate and the detection of cellular abnormalities showed some relation to spatula type. However, the satisfactory smears screened in the laboratory are routinely assigned a quality grade-good, fair or poor. Analysis shows higher rate of detection of cellular abnormalities in good quality smears, the detection of dyskaryosis being twice as high, in contrast to the fair or poor quality smears. It is suggested that quality grade is a better way of classifying smear quality in the cervical screening programmes rather than the presence or absence of endocervical and/or metaplastic cells.     

Diagnostic accuracy of squamous cervical lesions studied in spatula-cytobrush smears

The cytologically positive cases found in 25,300 cervical smears of spatula samples and 6,168 smears prepared by combined spatula-Cytobrush sampling were analyzed. The diagnostic accuracy (the correlation between the cytologic and histologic diagnoses) was the same for both types of sampling. As to the histologic diagnosis, the rates of severe dysplasia, carcinoma in situ and squamous carcinoma in the spatula-Cytobrush group were more than twice as high as in the spatula group. In the spatula group, the majority of abnormal cells was of the mature type. In the spatula-Cytobrush group, the majority of smears contained a mixture of immature and mature abnormal cells. The more immature lesions, which are often located higher in the endocervical canal, seem to be better sampled by the Cytobrush. The results indicate that the Cytobrush reaches areas that a spatula cannot reach, resulting in a higher diagnostic efficiency.     

Consequences of the introduction of combined spatula and Cytobrush sampling for cervical cytology. Improvements in smear quality and detection rates

One of the most important yardsticks for evaluating sampling for the detection of premalignant and malignant cervical lesions is the percentage of smears that contain cells from the transformation zone. Until February 1985, all smears made by around 500 different general practitioners were taken with a modified Ayre spatula. In the period February to October 1985, 24,496 smears of spatula samples and 5,716 smears prepared by combined spatula-Cytobrush sampling were analyzed. With the introduction of the combined spatula-Cytobrush method, the rate of smears containing cells from the transformation zone (adequate smears) rose from 84% to 98%. With the spatula-alone method, there were large differences between the rates of adequate smears from the various doctors; with the combined spatula-Cytobrush method, all participating doctors were without exception highly successful. The positive cytology rate was significantly higher in the combined spatula-Cytobrush smears (0.75%) as compared with the spatula-alone smears (0.38%). There was also a change in the diagnostic pattern in that more premalignant changes of the glandular epithelium of the endocervix were detected. One case of early invasive adenocarcinoma of the endocervix, in which the combined spatula-Cytobrush smears was positive and the repeat spatula-alone smear made by the gynecologist was negative, is discussed in detail. We anticipate that, with the large-scale introduction of the Cytobrush sampling method, fewer repeat smears will be required and, in addition, the observed relative increase of endocervical adenocarcinoma of the endocervix will be halted. In addition, there will be fewer false-negative smears.     

The endocervical smear as a simple and quick method for the determination of ovulation

The endocervix undergoes cyclic changes in every menstrual cycle, as reflected by the rheologic properties of the cervical mucus. A study was therefore undertaken to establish whether there were any morphologic changes in the endocervical columnar cells, as seen in the endocervical smears, that could be correlated with ovulation and anovulation. An endocervical smear was collected in the luteal phase of the cycle from patients in whom an endometrial biopsy or D & C was being done as a part of an infertility investigation. A significant correlation was observed between the endocervical smear interpretation and the endometrial histology as to whether the cycle was ovulatory or anovulatory.     

Aylesbury and cervitula spatulas: a comparative study to assess the adequacy of cervical smears

OBJECTIVE: To assess whether the Aylesbury (Pharmaceutical Enterprises Ltd., Pinelands, Capetown, South Africa) or Cervitula spatula (Harwill Medical, Capetown, South Africa) is more effective for adequate cervical smears in obstetric and gynecology patients. STUDY DESIGN: The Cervitula spatula was compared with the Aylesbury spatula by taking a total of 160 smears, which were examined cytologically. This consisted of 40 obstetric and 40 gynecology patients. The sequence in which the spatiulas were used was determined by computer randomization. Our main outcome criterion was whether both ectocervical and endocervical cells were present, thus making the smear adequate. Our numbers were too small to draw conclusions on the cytologic abnormalities detected between the two spatulas. RESULTS: The Cervitula was more effective for the identification of endocervical cells in obstetric patients (P = .0008). When combining the obstetric and gynecology groups, the Cervitula was also better in obtaining endocervical cells, but this did not reach statistical significance (P = .016). CONCLUSION: Pap smear sampling with the Cervitula reduces the number of cases without endocervical cells, which would constitute an inadequate smear, requiring unnecessary recall of patients for repeat smears.     

Pap smear adequacy--is the assessing criterion including endocervical cells really valid?

The significance of endocervical cylindrical cells (EC) as a criterion of sample adequacy has been established on 1,000 patients by comparing VCE smears (vaginal, cervical, endocervical) with or without EC in relation to prevalence of abnormal cells, prevalence of histological diagnosed lesions and sensitivity and negative predictive value of Pap smear, as well as by comparison of negative findings without EC with control smears with the aim of discovering overlooked lesions. A considerably greater yield of cytological (107/536 in relation to 49/464) and histological (105/536 in relation to 55/464) (p < 0.05) abnormalities in smears with EC support the hypothesis that the presence of EC is strongly and positively associated with prevalence of disease. In contrast, the presence of EC predicts only a moderate improvement in Pap smear quality with a weaker effect on sensitivity (95% in relation to 80%). During two-years monitoring of patients with negative Pap smear and negative colposcopy (403 with EC and 390 without EC in smears), no positive cytology/histology diagnosis was made. Also, because the prevalence of missed lesions among negative Pap smears is extremely low in absolute terms, no appreciable impact on negative predictive value was observed (98.8% in relation to 97.3%).     

Cytohistologic correlation between AGUS and biopsy-detected lesions in postmenopausal women

OBJECTIVE: To evaluate histologic findings in patients aged 50 and older whose cervical smears revealed atypical glandular cells of undetermined significance (AGUS). STUDY DESIGN: Computerized records spanning a four-year period were retrospectively analyzed. Thirty patients over age 50 had cervical smears interpreted as AGUS and had follow-up biopsies within 12 months following the abnormal smear. The most important histologic diagnosis from the biopsy specimens was correlated with the subcategory of the cervical smear. RESULTS: Five smears interpreted as AGUS, favor reactive, revealed abnormal histology in four cases: three endometrial polyps and one squamous carcinoma. Two smears interpreted as AGUS, favor dysplasia, revealed squamous intraepithelial lesions on biopsy in both cases. Seventeen smears interpreted as AGUS, favor endometrial cells, revealed abnormal histology in 13 cases: 1 endocervical polyp, 6 endometrial polyps, 3 endometrial hyperplasias and 3 adenomyosis. Six patients with smears interpreted as AGUS, unclassifiable, revealed abnormal histology in five cases: two endocervical polyps, one endometrial polyp, one endometrial carcinoma and one ovarian carcinoma. CONCLUSION: The presence of AGUS in cervical smears from women over 50 was highly predictive of abnormal lesions detected by histologic examination. Although three cancers were detected on histologic follow-up, the most common lesions detected were endometrial polyps.