Fine needle aspiration (FNA) cytology of the breast: the influence of unsatisfactory samples on patient management

FNA continues to play an important role in the management of patients with breast lesions. However, the reliability and efficiency of the FNA service depends heavily on the quality of the specimens. We have audited the rate of 'inadequate FNAs' at intervals over the last 5 years and related our findings to the clinical expertise of the aspirator. We have also correlated the rate of inadequate FNAs with the percentage of patients who had an FNA preceding a definitive diagnosis of cancer. We report trends in the rate of inadequate samples, and subsequent diagnosis of cancer, over a 5‐year period. The percentage of breast FNA samples reported as inadequate was 46.8% in 1988–89, falling to 20% in 1991–92 with the introduction of an FNA clinic, and rising to 30.6% in 1993. The rates of cancer following inadequate FNA were 15.7%, 16.1% and 4.2%, respectively, and the percentage of patients with cancer having a preceding inadequate FNA were 37.5%, 13.2% and 7.1%. Possible explanations for the apparent paradox between increasing numbers of inadequate FNA specimens and a falling breast cancer rate are discussed.     

The cervical smear test: does timing have an effect on sample adequacy?

OBJECTIVE: The aim of this study was to determine the effect of timing of the cervical smear test on sample adequacy. METHODS: Inadequate and negative smears from pre-menopausal women, with a regular menstrual cycle and who were not undertaking any hormone therapy, were selected and re-screened. The inadequate smears were then categorized according to the reasons for the inadequate result. The time of the cycle that the smear was taken was recorded for both inadequate and negative smears. The expected frequency of smears per phase was compared with the observed frequency per phase using the chi-squared statistical test. RESULTS: There was no significant difference between the overall observed and expected rate of the inadequate smears of nine general practitioner (GP) practices (P = 0.886), of GP practice 4 (lowest inadequate rate) (P = 0.610), or GP practice 6 (highest inadequate rate) (P = 0.621) at any phase of the cycle. CONCLUSION: Results show that there is no optimum phase for adequate sample collection, therefore it is suggested that there is no effect of timing of the cervical smear test on sample adequacy, that timing is not a relevant factor in reducing the inadequate smear rate, and restricting smear taking to mid-cycle is unnecessary. (The information regarding last menstrual period/length of cycle from which these conclusions were reached relied upon the accuracy of patient information given to the smear taker.).     

Cervical disease in women referred to colposcopy following inadequate smears

The aim of this audit was to determine if inadequate cervical smears are associated with significant cervical pathology. Case records for 52 women with three consecutive inadequate smears referred for colposcopy to the Leicester Royal Infirmary (LRI) were retrieved. Sixteen women underwent large loop excision of the transformation zone (LLETZ) and cervical intraepithelial neoplasia (CIN) was identified in six cases. There were no cases of inadequate smears initiating the diagnosis in 100 consecutive women with invasive cervical cancer. Inadequate smears are associated with high rates of treatment for a low yield of CIN. To reduce morbidity associated with colposcopy it may be acceptable to repeat an inadequate smear after 6 months rather than arranging immediate recall.     

The effect of lubricant contamination on ThinPrep® (Cytyc) cervical cytology liquid-based preparations

Objectives:  To assess the extent of lubricant use by smear-takers and the effect of lubricant contamination of ThinPrep^® processed cervical cytology samples.
Methods:  All primary care smear-takers were sent a questionnaire on lubricant type and frequency of use. Fifty cervical cytology samples were then contaminated with incremental amounts of K-Y^® jelly, 50 samples contaminated with incremental amounts of Aquagel^® and ten non-contaminated vials were processed using the ThinPrep^® T2000 processor followed by Papanicolaou staining. The morphological appearances of lubricant contamination were described microscopically and formal cell counts performed on all slides.
Results:  Seventy of 94 (74.5%) primary care smear-takers indicated lubricant use of whom 9/70 (12.8%) used Aquagel^® and 61/70 (87.2%) used K-Y^® jelly. K-Y^® jelly appeared as mucoid blue deposits in the slide background whereas Aquagel^® appeared as pink stringy background material. Cell counting showed a significant difference between Aquagel^® and K-Y^® jelly contaminated slides compared to the original non-contaminated preparations for all fields and the average fields ( P  < 0.001) with a significantly higher count for the original non-contaminated slides than the lubricant contaminated groups.
Conclusion:  Lubricant contamination of ThinPrep^® cervical cytology samples may result in reduced cellularity of the subsequent slide. This study provides evidence-based data to support British Society for Clinical Cytology recommendations for no lubricant use when taking cervical samples.     

Outcome of three consecutive inadequate cervical smears

A retrospective audit of women with three consecutive inadequate cervical smears during 1998-99 was conducted at Birmingham Heartlands Hospital. The commonest reasons were obscured by polymorphs (34.5%) and sparse cellularity (28.9%). Seventy-three per cent (73%) were followed up at colposcopy and 22.1% had histological assessment; 15.9% of women had an abnormality detected, 10.6% with abnormal histology and 5.3% with a cytological abnormality only. Cytological abnormalities were seen in 11.1% of the screening population. This study did not identify a cytological criterion to differentiate those that would or would not have an abnormality on follow-up. It is suggested that all women with three consecutive inadequate smears should have adequate follow-up, although this may place increased demands on colposcopy services.     

Outcome of women referred to colposcopy for persistently inadequate smears

The outcome of referral to colposcopy of 240 women who had persistently inadequate smears was investigated. Of 232 women who attended colposcopy, 214 (92.2%) had a normal outcome, 12 (5.2%) had low grade abnormalities, and six (2.6%) had high grade abnormalities. This group of women therefore has a negligibly increased risk of harbouring cervical neoplasia. Although not directly comparable, women with a history of previous abnormal cytology did not have a higher risk than those without such a history. Unnecessary colposcopy could have been avoided in the majority of cases if a good quality repeat smear had been taken. Improved smear taker training could decrease the number of referrals. A hospital cytology clinic is proposed as a cost-effective alternative to colposcopy at the first attendance.