Possible role of the micronucleus assay in diagnostics and secondary prevention of cervix cancer: a minireview

Recent literature data are presented concerning micronuclei (MN) frequency in exfoliated cells of cervix cancer patients. These data strongly support a positive correlation between the MN level and malignization (changes from premalignant stage to cancer). It is suggested that the evaluation of frequency of MN in exfoliated cervical cells may be an additional criterion for establishing cervical cancer risk and the study of MN in cervix smears will increase the sensitivity and specificity of cytology which could impact in diagnostics and secondary prevention of cervical cancer.     

Possible role of the micronucleus assay in diagnostics and secondary prevention of cervix cancer: A minireview

Recent literature data are presented concerning micronuclei (MN) frequency in exfoliated cells of cervix cancer patients. These data strongly support a positive correlation between the MN level and malignization (changes from pre-malignant stage to cancer). It is suggested that the evaluation of frequency of MN in exfoliated cervical cells may be an additional criterion for establishing cervical cancer risk and the study of MN in cervix smears will increase the sensitivity and specificity of cytology which could impact in diagnostics and secondary prevention of cervical cancer. The text was submitted by the author in English.     

Review of cervical smears from 76 women with invasive cervical cancer: cytological findings and medicolegal implications

OBJECTIVE: To review cervical smears from 76 women which were taken prior to the diagnosis of invasive cervical cancer and to determine the appropriateness of the cytology reports issued on the smears. METHODS: Cervical smears, clinical records, cervical smear history and cytology reports from 76 women with invasive cervical cancer were reviewed. After microscopic review of the cervical smears, the cases were divided into two groups: Group 1 comprised 50 women who were found to have had at least one false-negative (F/N) smear report prior to the diagnosis of invasive cervical cancer. Group 2 comprised 26 women for whom no evidence of F/N reporting was found. RESULTS: A total of 209 cervical smears from the 50 women in group 1 were available for review (range 2-12 smears per woman); 100 of the 209 smears were considered to have been reported appropriately. Ninety-seven smears which had been reported originally as negative or inadequate were found, on review, to contain numerous severely dyskaryotic cells and were reclassified as F/N smears. All of the 50 women had at least one F/N smear and 29 had two or more. Twelve smears from eight women contained only a few (<200 severely dyskaryotic cells). Forty women developed invasive squamous carcinoma and 10 developed invasive adenocarcinoma. The stage at diagnosis ranged from 1A to stage 4. Seventy-one smears from the 24 women in group 2 were available for review (range 1-15 smears per woman). In two cases included in group 2, no smears were provided for review as the smears had been lost or mislaid. Review of the 71 smears confirmed the accuracy of the original cytological classification of the smear. Nineteen women were diagnosed with squamous cancer, two microinvasive cancer, one glassy cell, two adenocarcinomas, and one with adenosquamous carcinoma. One women was found to have an embryonal rhabdomyosarcoma of the corpus uteri involving the cervix. DISCUSSION/CONCLUSION: The medicolegal implications are discussed in the light of the above findings. Evidence of breach of duty of care was presented in all 50 cases in group I although causation was not established in every case. There was no evidence of failure of duty of care in terms of the standard of the cervical cytology reports issued or standard of clinical management in 17 of the 26 cases in group 2. However, in seven of the 26 cases in group 2, clinical management of the case was substandard due to failure to investigate symptoms of irregular bleeding regardless of a negative cytology report (two cases), failure to act upon a suspicious smear report or consecutive inadequate smear reports (two cases), failure of follow-up after treatment of CIN3 (two cases) and histological misdiagnosis (one case).     

A review of post-trachelectomy isthmic and vaginal smear cytology

Currently in the UK cervical cancer has a peak incidence in women aged 35-39. Fertility-conserving surgical treatment by radical trachelectomy is established in the management of early disease. This study aimed at establishing the value of cytology in follow-up after trachelectomy. The cytological features of isthmic-vaginal smears post-trachelectomy for cervical cancer are presented together with a discussion of relevant clinical issues. One hundred and ninety seven smears from 32 women were reviewed. Two of the 32 patients developed pelvic recurrences. In both cases recurrence was detected cytologically long before development of a clinical or radiological abnormality. There is, however, a potential for overcall due to the presence of endometrial cells. These were present in large numbers and varying configurations in 58% of smears and led to a false positive report of malignancy in 2% of smears. The rate of referral for a cytologist opinion was significantly higher in smears containing endometrial cells (26%) than those without (13%). While all smears contained squamous cells, 41% contained squamous cells only and it is proposed that such smears should be reported as unsatisfactory in the first 2 years after surgery and negative thereafter, although the absence of glandular cells should be recorded. When an abnormality is reported, smear review and multidisciplinary discussion may avoid unnecessary investigations.     

An Audit of Cervical Cancer Deaths In Nottingham

Death certificates were reviewed and 57 women were identified whose primary cause of death was cervical cancer. Their cervical smear records were reviewed from laboratory files. Only nine had participated in the cervical cancer screening programme before the diagnosis of cervical cancer was made. One woman had an abnormal smear as a result of cervical screening but failed to attend for follow-up.
The problem of false negative smears is also addressed and the value of review of negative smears for the purposes of cytology audit is emphasized.     

Review of negative and low‐grade cervical smears in women with invasive cervical cancer after the first 3 years of the national cervical screening programme in Slovenia

A. Repše‐Fokter, A. Pogačnik, V. Snoj, M. Primic‐Žakelj and M. S. Fležar
Review of negative and low‐grade cervical smears in women with invasive cervical cancer after the first 3 years of the national cervical screening programme in Slovenia Objective: The purpose of the study was to perform a national review of negative, low‐grade and inadequate smears reported during the latest screening period before cervical cancer diagnosis in 2006, after the first 3 years of the screening programme. Methods: Among 162 new cervical cancer cases there were 47 (29%) without previous cytology, 47 (29%) with one high‐grade smear prior to diagnosis and 68 (42.0%) with at least one previous negative, low‐grade, atypical or inadequate smear 1–40 months before diagnosis. Of the latter 68 cases, 37 patients with 59 smears (together with 118 control slides) were included in the review as 31 had smears reported at laboratories no longer operating. Findings were related to the last cytology report before diagnosis as well as to histological type and stage of the cancer. Results: In our study group, 19 (51%) of 37 patients had squamous cell carcinoma, 15 (41%) adenocarcinoma and 3 (8%) adenosquamous carcinoma, compared with 121 (75%), 26 (16%), 12 (7%), respectively, and 3 (2%) other types, for all carcinomas. Twenty‐one of 37 women also had high‐grade cytology prior to diagnosis of cancer. Women with previous cytology (with or without recent high‐grade smears) were more likely to have stage I cancers than those without cytology (P < 0.0001). The expert group upgraded 17/33 smears in the patients with squamous carcinomas, which was more than in those with adeno‐ and adenosquamous carcinomas (5/24, P < 0.05). Conclusion: As expected, a higher proportion of smears preceding adenocarcinomas were true negative. Under‐diagnosed smears were not related to cancer stage or last cytology report before diagnosis.     

Clinical relevance of human papillomavirus testing in cytopathology

Cancer of the uterine cervix is the second most common cancer in women worldwide. Currently, cervical screening is based on cytology alone. Because infection with high-risk human papillomavirus types (hrHPVs) is a necessary cause of cervical cancer, it has been postulated that screening might become more efficient when it is based on combined cytology and hrHPV testing. In this review we will discuss the advantages of added HPV tests in cervical cancer screening, as a quality control for false-negative smears, in triage of women with equivocal smears, in follow-up of women treated for CIN3 or cervical cancer and for the detection of cervical adenocarcinoma.     

Detection of sexually transmitted diseases by urethral cytology, the ignored male counterpart of cervical cytology

The detection of sexually transmitted diseases by urethral cytology was investigated in 270 men examined by urethral swabbing smears. Each sample was used to prepare a wet mount smear and smears for staining by the Papanicolaou, Gram and methylene blue techniques. A fifth smear was used for direct staining with fluorescein-conjugated monoclonal antibodies for the detection of Chlamydia trachomatis. The smears were examined for cytoplasmic and nuclear changes as well as for pathogenic organisms and inflammatory changes. Infections with Chlamydia trachomatis, Neisseria gonorrhoeae and human papillomavirus (HPV) produced distinctive cytologic patterns similar to those seen in cervicovaginal smears from women. The patterns in candidiasis, trichomoniasis and herpes simplex virus infection were not as diagnostic. Particularly noteworthy were the nuclear alterations, which appeared to be proplastic in HPV infection but retroplastic in Chlamydia infection. The results of this study indicate that urethral cytology would be an invaluable addition in diagnosing sexually transmitted diseases in men, particularly in the case of Chlamydia and HPV infections. The monomorphic structure of urethral columnar epithelium, as compared to the cervical epithelium, seems to result in a clearer and more constant response to pathogenic infections, as seen in the resulting smears.     

The cytology of vaginal, cervical and endometrial smears obtained at the time of embryo transfer during in vitro fertilization

Seventy-four women enrolled in an in vitro fertilization (IVF) program had cytologic smears of the vagina, cervix and endometrium obtained at the time of embryo transfer (ET). Of these, 68 vaginal, 46 cervical and 25 endometrial smears were available for cytologic examination. Of the 68 vaginal smears, 4% showed a proliferative pattern, 40% were early secretory and 56% were advanced secretory. The 46 cervical smears demonstrated a delayed hormonal effect, with 70% showing a proliferative pattern, 23% early secretory and 7% advanced secretory cytology. Endometrial cells were obtained only when the Jones catheter, which has a side opening, was used. Twenty-two patients had both vaginal smears and suitable endometrial smears. Of these, 8 of the 9 patients with early secretory vaginal cytology had secretory endometrium while 10 of the 12 patients with mid-secretory vaginal cytology had secretory endometrium. The value of endometrial cytology in predicting conception following IVF-ET is unknown. It seems, however, that a good correlation exists between endometrial and vaginal cytology and that the latter may be of value as an additional, noninvasive tool for the evaluation of endometrial development.     

Color image analysis of cervical neoplasia using RGB computer color specification

OBJECTIVE: To establish quantitative color image analysis for cytology, red, green and blue (RGB) color specification was applied to Papanicolaou-stained cervical smears. STUDY DESIGN: Cell samples used in this study was those from 300 cervical specimens. We analyzed the color tone of nuclei and cytoplasm of the squamous cells in the cervical smear by means of computer image analysis. RESULTS: Papanicolaou stained nuclei displayed basophilic blue to purple. When they were hyperchromatic and deeply stained, B and G values decreased in value. The RGB values of cytoplasm and nuclei decreased significantly (P < .01) as their degree of cellular atypia increased. CONCLUSION: Using RGB color specification to analyze Papanicolaou-stained cervical smears, a significant difference was perceived in the nucleus and cytoplasm between different groups of squamous cells, from normal, dysplastic and squamous cell carcinoma. These findings may help to establish automated cytology.     

Evaluation of p16INK4a in cervical lesion of premenopausal and postmenopausal women

Pap smears of postmenopausal women are often misdiagnosed because of the difficulty in distinguishing atrophic epithelial cells groups only by morphological criteria. In this study we investigated the diagnostic application of immunocytochemical staining of p16INK4a on conventional Pap smear. A total of 137 cervical specimens were enrolled in this study, of which 77 and 60 cervical smears were taken from premenopausal and postmenopausal women, respectively. Two cervical smears were taken simultaneously in 68 women, one for conventional cytology and the other for immunostaining. Additional 69 cervical smears were taken from the archive, decolorized and then used for immunostaining. In premenopausal women 1 out of 14 (7.1%) with negative cytology, 7 out of 24 (29.2%) with low grade squamous intra-epithelial lesion (LSIL), all 35 (100%) with high grade squamous intraepithelial lesion (HSIL) and all 4 (100%) with squamous cell carcinoma (confirmed by histopathology) had positive staining to p16INK4a. In postmenopausal women p16INK4a positivity was observed in 4 out of 7 (57.1%) cases of LSIL, 12 out of 14 (85.7%) cases of HSIL and all 4 out of 5 (80%) different cases of carcinoma (1 cervical adenosquamous carcinoma and 3 cervical squamous cell carcinoma in situ confirmed by histopathology), but none of 34 smears with normal cytology. Twenty smears with normal cytology chosen for the negative control in this study were from the group of postmenopausal women and were as expected negative for p16INK4a immunostaining. In the group of postmenopausal women, 16 out of 60 (26.7%) cases the cytological diagnosis was established on the basis of pl6lNK4a immunostaining as being HSIL. From our preliminary study on a limited number of samples, we can however conclude that pl6INK4a immunostaining is a very useful tool for cytological diagnosis enabling to distinguish HSIL from normal, reactive or inflammatory changes.     

Exfoliative cytology in the evaluation of interferon treatment of cervical intraepithelial neoplasia

Local interferon injection in four patients with cervical intraepithelial neoplasia (CIN) regularly elicited progressive regression of the lesions. The response was observed with exfoliative cytology after each injection, guided by colposcopic examination. The cytologic changes showed a cytocidal effect mainly on the dyskaryotic cells, preceded by cellular degeneration not unlike that of nonspecific inflammation and accompanied by an increase in neutrophil infiltration. The cytologic response was closely correlated with partial or complete clinical regression based on the absence of viable or degenerated dyskaryotic cells in the cervical smears. Three patients showed complete clinical regression after treatment. One patient showed recurrent viable dyskaryotic cells when the dosage was reduced, and treatment was suspended temporarily although her lesion had regressed completely after five injections. Clinical recurrence was noted one week after viable dyskaryotic cells reappeared in her smears. These observations suggest that cytology may be a useful means of monitoring interferon treatment in CIN.     

Cervicovaginal cytology in an indigent population. Comparison of results for 1964, 1981 and 1989

To evaluate the usefulness of cervicovaginal cytology in decreasing the incidence of cervical carcinoma in an indigent population, the cytologic findings from 10,000 consecutive smears in 1964 (when cytology screening started) were compared to the results of 10,000 consecutive smears in 1981 and 1989. There was a marked (statistically significant) decrease in invasive cervical squamous carcinoma at all ages between the first and later periods. Squamous carcinoma in situ showed a significant decrease beginning in patients under 40 in 1981. The number of atypias and mild dysplasias showed a proportional increase, from 2% in 1964 to 13.4% in 1981 to 21.8% in 1989, predominantly in young patients. These results reaffirm that cervicovaginal cytology remains the most inexpensive and effective diagnostic tool for the elimination of cervical cancer.     

The role of cervical cytology and colposcopy in detecting cervical glandular neoplasia

Objective:  To determine the role of cervical cytology and colposcopy in the management of endocervical neoplasia.
Setting:  Colposcopy unit and cytology laboratory in a teaching hospital.
Sample:  Group 1 included 184 smears showing endocervical glandular neoplasia from 129 patients and group 2 included 101 patients with histology showing endocervical abnormalities in a 6-year period (1993–1998). Follow-up of 6–11 years to 2004 was available.
Methods:  Group 1 were identified from the cytology computer records. Group 2 were identified from histology records on the cytology database and a record of histology cases kept for audit purposes. The clinical records were examined retrospectively.
Results:  The positive predictive value (PPV) of abnormal endocervical cells in smears was 81.1% for significant glandular/squamous [cervical glandular intraepithelial neoplasia (CGIN)/cervical intraepithelial neoplasia grade2 (CIN2 or worse)] lesions. The PPV of colposcopy was 93.5% for significant glandular/squamous lesions of the cervix. The postcolposcopy probability of a significant lesion when colposcopy was normal was 87.5%. The sensitivity of colposcopy in detecting endocervical lesions was 9.8%. The sensitivity of cervical smears in detecting a significant endocervical abnormality (CGIN or worse) was 66.3%. The false negative rate for cytology of endocervical glandular lesions was 4.0%.
Conclusions:  Endocervical glandular neoplasia detected on cytology is predictive of significant cervical pathology even when colposcopy is normal, which supports excisional biopsy in the primary assessment of these smears. The high concomitant squamous abnormality rate justifies the use of colposcopy to direct biopsies from the ectocervix. Cervical cytology is the only current screening method for cervical glandular abnormalities but sensitivity is poor.     

Impact of liquid-based gynecologic cytology on an HIV-positive population

OBJECTIVE: To examine the imprint of liquid-based technologies for cervicovaginal cytology on HIV-positive women, who are at high risk for cervical intraepithelial neoplasia. STUDY DESIGN: We performed a retrospective search of the cytopathology files of Johns Hopkins Hospital for the cervicovaginal cytology of HIV-positive women to examine the effect of liquid-based technology on this population. RESULTS: Significant intraepithelial lesions (SILs) (low grade SIL or greater) were identified in 24% of the conventional smears and 23% of the liquid-based cytology. Atypical squamous cells of undetermined significance (ASCUS)/atypical glandular cells of undetermined significance was diagnosed in 15% of the conventional smears and 9% of the liquid-based preparations (P = .02). In patients with ASCUS diagnoses and tissue follow-up within 7 months, significant SILs were identified in 29% with conventional smears and in 65% with liquid-based cytology. CONCLUSION: There was no statistically significant difference in the rate of SILs between conventional smears and liquid-based cervicovaginal preparations in HIV-positive women. The diagnosis of ASCUS on liquid-based cytology may have an increased likelihood of representing a significant SIL in comparison to conventional smears. For the high-risk, HIV-positive population, immediate colposcopy and biopsy may be warranted following ASCUS diagnoses on liquid-based cytology.     

Cellular Differences Between True Negative and False Negative Papanicolaou Smears

A matched case-control study of 123 false negative Papanicolaou smears and 488 true negative Papanicolaou smears was undertaken to determine the association between the types of cells present on the smear and the correctness of the cytology report. the false negative slides were significantly more likely to include endocervical columnar cells than the true negative slides (odds ratio 1.90, 95% confidence interval (CI) 1.21–3.01). No statistically significant difference in metaplastic cell status was evident (odds ratio 1.48, 95% CI 0.95–2.30). When considered together, metaplastic and/or columnar cells were significantly more likely to be present in false negative smears than in true negative smears (odds ratio 1.87, 95% CI 1.13–3.08). the implications of these findings for improving the accuracy of cervical cytology for the detection of precancerous lesions are discussed.     

Cytology and clinical spectrum of sexually transmitted infections in Lebanese women as revealed by Pap smear: a cross-sectional study from 2002-2006

To study the cytology profile of cervical smears and the respective prevalence and incidence of certain cervico-vaginal infections detectable by routine Pap smear cytology in Lebanese women from 2002 to 2006. Pap smear cytology results were compiled from the archives of the Institut National de Pathologie for the period extending from 2002 until 2006. This study covered 118,230 cervical specimens obtained from Lebanese women attending clinics and hospitals in all the five districts of Lebanon; prevalence and incidence rates for infections detectable by routine Pap smear examination were determined. A rise in prevalence of these infections by 2.1 percent (2,555) from 2002 to 2006 was revealed. A doubling of Pap smears showing HPV-associated changes was detected (1.4 percent in 2002 to 2.9 percent in 2006), and a simultaneous almost 7-fold increase of Atypical Squamous Cells of Undetermined Significance (ASCUS) cytology was detected during this period; the rise in ASCUS cytology was age-dependent. Moreover, a 60 percent increase in prevalence of bacterial vaginosis (2.3 percent in 2002 to 3.7 percent in 2006) and a more than 3-fold decline in Trichomonas vaginalis infection (1 percent in 2002 to 0.3 percent in 2006) were also noted in this population during this period. An increase in the prevalence and incidence of cervico-vaginal infections detectable by Pap smear cytology in Lebanese women was revealed from 2002 to 2006. Such changes could point to recent modifications of sexual and health behaviours in the Lebanese community.     

Clinico-cytological study of uterine papillary serous carcinoma

OBJECTIVE: The aim of this study was to determine whether or not we could distinguish uterine papillary serous carcinoma (UPSC) from other types of endometrial cancer by cytology. METHODS: We examined the cytological findings of the endometrium from five cases with UPSC and compared them with 10 cases with endometrioid adenocarcinoma, grade 1 (G1). A morphometric analysis was performed. Cytological samples from the cervix and ascites of the patients with UPSC were also reviewed. RESULTS: All five patients had FIGO stage III and IV tumours. Three patients died of the disease and two are still alive with disease. The tumour cells of UPSC tended to be shed in papillary clusters with a tumour diathesis. Psammoma bodies were seen only in UPSC. The frequency of irregular-shaped nuclei, membrane thickness and eccentric nuclei in UPSC was higher than in G1. The chromatin pattern was coarsely granular, and both anisonucleosis and bare nuclei were prominent in UPSC. Cytomorphometrically, the maximum diameter of the nuclei in UPSC was significantly greater than that in G1. The nucleoli were also more often seen in UPSC than in G1. The findings of the nuclei and nucleoli in the cervical and peritoneal fluid cytology closely resembled those in endometrial smears. The features of the cervical smears and peritoneal fluid cytology were different from those of endometrial cytology regarding clear background and small clusters of cells. CONCLUSION: As the endometrial cytology findings accurately suggested the histological diagnosis of UPSC, the diagnosis of UPSC was confirmed in this study by endometrial cytology. The cytological diagnosis of UPSC should be based on the findings of tumour diathesis, psammoma bodies and papillary clusters composed of tumour cells with enlarged nuclei and numerous nucleoli.     

Cervical and peritoneal fluid cytology of uterine sarcomas

OBJECTIVE: To study the cytologic features of uterine sarcoma. STUDY DESIGN: The pathology records of 102 patients with uterine sarcoma were reviewed. Four patients, including one case of leiomyosarcoma (LMS), one high grade stromal sarcoma (HGSS) and two malignant mixed müllerian tumor (MMMT), had abnormal cervical and/or peritoneal cytologic findings. Three abnormal cervical smears and two abnormal peritoneal fluids from these patients, including immunohistochemically stained sections of cell block, were reviewed. RESULTS: The diagnostic cells appeared in clusters or in isolation. They had enlarged and hyperchromatic nuclei. Occasional mitotic figures were seen. The cells were considered suspicious for malignancy in cervical smears of HGSS and in the peritoneal fluid of LMS. Adenocarcinoma cells were identified in both the cervical smear and peritoneal fluid of one patient with MMMT. Atypical cells were found in another patient with MMMT. CONCLUSION: Positive cervical or peritoneal cytology is uncommonly detected in association with uterine sarcomas. Even when abnormal cells are found, it may be difficult to give a definitive diagnosis of uterine sarcoma based directly on the cytomorphologic characteristics of cervical or peritoneal smears. However, such a possibility should be kept in mind by the cytopathologist to avoid missing the diagnosis.