Bethesda Classification System Research Articles

HPV Type Distribution and Cervical Cytology among HIV-Positive Tanzanian and South African Women

Background. There are limited data on high-risk human papillomavirus (hr-HPV) genotypes among HIV-positive women in Africa, and little is known about their relationship with cervical cytology in these populations. Methods. We conducted a cross-sectional study among 194 HIV-positive women (143 from Tanzania, and 51 from South Africa) to evaluate HPV genotypes among HIV-positive women with normal and abnormal cytology. Cervical samples were genotyped for HPV types, and slides were evaluated for atypical squamous cell changes according to the Bethesda classification system. Results. Prevalence of high grade squamous intraepithelial dysplasia (HSIL) was 9%. Overall, more than half (56%) of women were infected with an hr-HPV type; 94% of women with HSIL (n = 16), 90% of women with LSIL (n = 35), and 42% of women within normal limits (WNL) (n = 58) tested positive for hr-HPV. Overall, the most prevalent hr-HPV subtypes were HPV16 (26%) and HPV52 (30%). Regional differences in the prevalence of HPV18 and HPV35 were found. Conclusion. Regional differences in HPV genotypes among African women warrant the need to consider different monitoring programmes for cervical preneoplasia. HPV-based screening tests for cervical preneoplasia would be highly inefficient unless coupled with cytology screening of the HPV-positive sample, especially in HIV-positive women.

29. Audit of fine needle aspiration cytology assessment of thyroid nodules

Fine-needle aspiration (FNA) is one of the first line investigations used to triage patients with suspected thyroid pathology. The introduction of the Bethesda Classification System for reporting thyroid cytopathology in 2007 aimed to create universal standards which would contribute to the most appropriate patient management. We audited our experience with this system for the calendar year 2010. We examined 495 thyroid FNA samples from 355 patients. Of the 495 FNAs, 17.4% were category 1 non-diagnostic, 70.7% were category 2 benign, 4.4% were category 3 atypical, 4% were category 4 suspicious for follicular neoplasm, 0.4% were category 5 suspicious for carcinoma and 3% were malignant. All category 5 and 6 cases were found to be malignant at surgery. There was limited follow-up for categories 3 and 4. For category 3, 88% were benign at surgery or category 2 at follow up FNA, with 12% being upgraded to category 4 at repeat FNA (no follow up surgical data available). For the 20 category 4 cases definitive surgical follow-up was only available in eight cases, with five (63%) being benign and three (37%) representing follicular carcinoma. Given that we review most follicular carcinomas resected elsewhere but biopsied in our unit, we suspect that the true rate of malignancy for category 4 aspirates in our unit is 15%.

Incidence of Malignancy in Thyroid Nodules Determined to be Follicular Lesions of Undetermined Significance on Fine‐Needle Aspiration

Fine-needle aspiration (FNA) for thyroid nodules is the most important method for determining a diagnosis. The system for reporting results is based on a cytopathologic classification that stratifies the risk of malignancy. We retrospectively studied 197 patients who underwent FNA for diagnostic evaluation of a thyroid nodule and had their results reported as a follicular lesion of undetermined significance (FLUS) using the Bethesda classification system. The objective of the study was to analyze the incidence and histopathologic types of malignancy in these cases. The final histopathologic breakdown is as follows: 65 cases (32.9%) of follicular adenoma, 81 cases (41.1%) of microfollicular adenomatoid nodule, 19 cases (9.6%) of microfollicular adenomatoid nodule on the background of thyroiditis, 17 cases (8.6%) of follicular carcinoma, 9 cases (4.6%) of follicular variant papillary carcinoma, and 6 cases (3.1%) of classic papillary carcinoma, for a 16.2% incidence of malignancy. Beyond these diagnoses in the FNA-biopsied nodules, we observed 29 cases (14.7%) of incidental ipsilateral papillary thyroid microcarcinoma (PTM) and 13 cases (6.6%) of incidental contralateral thyroid lobe PTM. This study observed a 16.2% incidence of thyroid cancer in the nodule designated FLUS compared to the 5 to 15% rate reported by the Bethesda FNA classification. The overall incidence of incidental PTM in the thyroid gland was 21.3%. These data support considering surgical intervention for at least diagnostic purposes in a patient with the FNAB diagnosis of FLUS.

Value of Ultrasound and Cytological Classification System to Predict the Malignancy of Thyroid Nodules with Indeterminate Cytology

Although fine-needle aspiration cytology is considered the gold standard for evaluating thyroid nodules, in about 10-30% of the cases, cytology is indeterminate. This study aimed to determine the value of cytological classification system and ultrasound (US) to predict malignancy in indeterminate thyroid nodule. This retrospective analysis enrolled 80 patients surgically treated at a single center, 75% (60) with benign vs. 25% (20) with malignant lesions at final histology. The clinical, scintigraphic, sonographic, and cytological classification (Bethesda) variables were analyzed in these selected cases of indeterminate cytology, and a prediction model was designed after the multivariate analysis. There was a 25% prevalence of malignancy (20/80). There were no differences in gender, serum thyroid-stimulating hormone and FT4 levels, thyroid auto-antibodies, thyroid dysfunction, and scintigraphic results between benign and malignant nodule groups. The border irregularity in sonographic study was at increased risk for malignancy. The cytological analysis based on Bethesda System (category IV) was an independent predictor for malignancy in indeterminate thyroid nodules. After the multivariate analysis, the model obtained showed border irregularity and Bethesda System category IV as predictive factors of malignancy in indeterminate thyroid nodules, featuring 76.9% of accuracy. This study confirmed a significant increase of risk for malignancy in thyroid nodules with indeterminate cytology showing Bethesda System category IV and suspicious features at US. These findings enhance our current limited predictive armamentarium and can be used to guide surgical decision making.

Value of repeat ultrasound-guided fine-needle aspiration in thyroid nodule with a first benign cytologic result: Impact of ultrasound to predict malignancy

This study aimed to investigate the value of repeat ultrasound-guided fine-needle aspiration (FNAC-US) in benign thyroid nodules and determine the ultrasound (US) predictors of malignancy in this group of nodules. The authors studied 35 of 143 nodules with initially benign cytological result who underwent serial re-biopsy (FNAC-US). By means of surgery, malignancy histology results were confirmed in 10 (28.5%) cases (G1) versus 25 (71.5%) benign nodules (G2). The clinical, lab, scintigraphyc, and US features were compared between the two groups to predict malignancy in thyroid nodules with initially benign cytological result. The cytological finding of 28/35 nodules were change to indeterminate cytology (Bethesda system category III or IV) at second and/or ≥third cytological study. In this group of 28 cases, 23 (82.1%) was identified until the third procedure. The interval between first and third re-biopsy was 13months (median). There were no differences in age, gender, thyrotropin (TSH) levels, thyroid auto-antibodies, or thyroid dysfunctions. The scintigraphy showed cold nodule in 80% of G1 versus 78.9% of G2 (NS). Sonographic studies showed malignant suspected US features in G1: microcalcifications, central flow, hypoechogenicity, and border irregularity. This study suggests repeating FNAC-US in nodules with first benign cytologic result and suspicious US features of malignancy for at least two times (until the third FNAC) in about 13months horizon.

Adoption of HPV testing as an adjunct to conventional cytology in cervical cancer screening in Japan

Objective To assess the effectiveness of including HPV testing as an adjunct to conventional cytology in cervical cancer screening. Methods Atypical epithelial cells (ATC) were classified according to the 2001 Bethesda classification system. The study ran for 6 years from May 2004 to November 2009 in conjunction with public cervical cancer screening for Kanazawa City residents. Patients with ATC (ASC-US, ASC-H, and AGC) underwent parallel testing for high-risk HPV types with the Hybrid Capture II system; HPV positive and cytology-ATC cases were recalled for colposcopic examination and biopsied if necessary. Results were compared with those obtained before HPV screening was initiated. Results A total of 62 645 women underwent screening over the 6-year period; of these, 3622 (5.8%) were ATC positive, among whom 527 (14.5%) tested HPV-positive. These 527 women (0.8% of the screened population) were recalled for colposcopic examination. The resulting 426 biopsies were diagnosed as CIN 1 (n = 187), CIN 2 (n = 53), CIN 3 (n = 11), and invasive cervical cancer (n = 2). Conclusion HPV testing as an adjunct to conventional cytology in cervical cancer screening seems to increase detection sensitivity with proven cost-effectiveness.

Application of Bethesda System for Reporting Thyroid Aspiration Cytology

Background : The Bethesda classification system for reporting on thyroid fine-needle aspiration (FNA) cytology was recently proposed by the National Cancer Institute, USA. We aimed to report our experience with applying this system for thyroid FNA, with a focus on comparing it with the four categorical system. Methods : We retrospectively reviewed the 4,966 thyroid FNAs that were performed at the Seoul St. Mary’s Hospital between October 2008 and September 2009. All the FNAs were classified according to the Bethesda system and the four tier system. Results : The cytologic diagnoses of the Bethesda system included 10.0% unsatisfactory, 67.7% benign, 3.1% atypia of undetermined significance, 0.6% follicular neoplasm, 0.5% follicular neoplasm, Hurthle cell type, 5.1% suspicious for malignancy and 13.0% malignancy. Using four tier system, 10.1%, 67.6%, 9.3%, and 13% were diagnosed as unsatisfactory, negative for malignancy, atypical cells and malignancy, respectively. Of the 4,966 nodules, 905 were histologically confirmed. The specificity of the Bethesda system and the four tier system for diagnosing malignancy was 99.6% and 82.6%, respectively. Conclusions : The Bethesda system can classify indeterminate thyroid nodules into more detailed categories and provide clinicians with useful information for management.

Cervical cytology of atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion (ASC-H)

The 2001 Bethesda System category of atypical squamous cells (ASC) denotes changes suggestive, but inconclusive for, a squamous intraepithelial lesion (SIL). ASC is subcategorized as: 1) "undetermined significance (ASC-US)," when changes suggest low-grade or indeterminate-grade SIL and 2) "cannot exclude high-grade squamous intraepithelial lesion (ASC-H)," when a cancer precursor is suspected. To better define the characteristics of ASC-H, the authors analyzed and compared human papillomavirus (HPV) testing data and outcomes after 2 years for participants in the Atypical Squamous Cells of Undetermined Significance Low-Grade SIL Triage Study (ALTS), a randomized trial of 5060 women. Among women with thin-layer cytology findings of ASC-H, 84% tested positive for HPV, 50% (95% confidence interval [95% CI], 41%-60%) were diagnosed with cervical intraepithelial neoplasia (CIN) type 2+, and 30% (95% CI, 22-39%) were diagnosed with CIN3+. Positive HPV tests and diagnoses of CIN2+ and CIN3+ were found to be more common among women with ASCH compared with those with ASC-US, but the highest frequencies were found to be associated with high-grade SIL. For women age < 35 years with ASC-H, HPV detection exceeded 85%, whereas only 4 of 10 women (40%) age >/=35 years tested positive for HPV (P = 0.009). A finding of ASC-H seems to confer a substantially higher risk for CIN2+ and CIN3+ than ASC-US. Immediate colposcopy may be the appropriate management for young women with ASC-H, but the utility of HPV testing for managing older women with ASC-H requires additional study.

Histologic Implications of Pap Smears Classified as Atypical Glandular Cells

This study was conducted to investigate the correlation between cytologic findings and histologic diagnoses in cervical smears classified as atypical glandular cells (AGC). A review of the medical records from 41,400 Pap smears performed during the 2-year period from January 2000 to January 2002 identified 113 (0.27%) women with a diagnosis of AGC. All smears were reclassified to conform to the 2001 Bethesda System categories, which are: AGC not otherwise specified (AGC NOS), AGC favor neoplasia, and endocervical adenocarcinoma-in situ. All patients were evaluated with colposcopy and endocervical curettage. Women over age 35 years also underwent endometrial biopsy. Ectocervical biopsies were taken in patients whose Pap smears also contained abnormal squamous cells. In patients whose smears were diagnosed as cervical adenocarcinoma-in situ, a cone biopsy was done. Study subjects were an average age of 52 years. Two thirds (77 of 113; 68%) of patients were 45 years or more. Sixty-four (57%) had a diagnosis of ACG NOS. There were 48 women with a diagnosis of AGC favor neoplasia (43%) and a single patient was diagnosed with adenocarcinoma-in situ. In 27 patients (24%), a squamous abnormality, including ASCUS or cervical intraepithelial neoplasia (CIN), was also diagnosed on the cervical smear. Endometrial disease was diagnosed in 14 women, including 9 (8%) with endometrial adenocarcinoma and 5 (4.4%) with endometrial hyperplasia. Of 16 patients with significant squamous cell abnormalities, 13 were found to have CIN, whereas only 3 had invasive squamous cell carcinoma of the cervix. The mean age of women with squamous abnormalities was 42 years, significantly lower than the mean age of 58 in women with endometrial lesions (P = .009). When a diagnosis of AGC NOS was made, only 10.9% (7 of 64) of patients were found to have a significant lesion. This is much less than the 46% (22 of 48) who had a significant lesion identified after a diagnosis of AGC favor neoplasia (P <.001). The patient who had a cervical smear diagnosed as adenocarcinoma-in situ was found to have endometrial adenocarcinoma on cone and endometrial biopsy.

Screening Methods for High-Grade Dysplasia in Patients with Anal Condyloma 1

Human papilloma virus (HPV) is one of the most common sexually transmitted diseases in the United States. HPV infection can cause anal condylomas and is a risk factor for dysplasia. High-grade dysplasia may progress to squamous cell carcinoma. Currently, biopsy and histological examination are required to grade dysplasia. The purpose of this study is to determine whether anal cytology, morphological characteristics, and/or the presence of high-risk oncogenic HPV-types are effective noninvasive methods to detect high-risk anal condylomas. From November 2003 to June 2004, all patients with anal condyloma were prospectively evaluated for anal cytology, high-risk oncogenic HPV-types, and tissue biopsies. The Bethesda classification system was used to classify cytologic findings and histological examination, which were grouped as high-risk (HRL) and low-risk (LRL) lesions. Histology results served as true disease for all comparisons. Forty-seven patients with anal condyloma were studied; 43 (91.5%) were men, and the mean age was 39 +/- 11 years. Histology showed 19 (40.5%) patients with HRL, and 28 (59.5%) patients with LRL. Cytology correctly identified 8 patients with HRL and 27 patients with LRL (sensitivity 42% and specificity 96%). High-risk oncogenic HPV-types were found in 84.2% of HRL and 39.3% of LRL (P = 0.0029). Combining cytology with oncogenic HPV-testing, the sensitivity of detecting HRL increased to 89%, and specificity decreased to 42%. Anal cytology alone is not accurate for detecting HRL in patients with anal condylomas. Combining oncogenic HPV-testing with cytology is more sensitive in detecting HRL in patients with anal condyloma, and therefore, a more effective screening tool.

Prevalencia de lesiones cervicales premalignas y malignas

En el Hospital de San José desde diciembre de 2001 se viene realizando el control de calidad de las citologías cervicovaginales (CCV) del programa de Promoción y Prevención (P y P) de una EPS, que tiene por objetivo identificar en forma oportuna las lesiones precancerosas del cuello uterino. Este estudio se realizó para determinar la prevalencia de las lesiones premalignas y malignas en las CCV del programa entre enero de 2002 y diciembre de 2003. Se evaluaron 162.487 CCV, clasificadas según las categorías del sistema Bethesda, se determinó la prevalencia anual de citologías positivas y la prevalencia anual por cada categoría de lesión. Se encontró similitud de la prevalencia anual de cada lesión, lo que indica resultados satisfactorios para el programa de P y P. Adicionalmente se realizaron comparaciones con cifras nacionales de la Liga de Lucha Contra el Cáncer y La Secretaría Distrital de Salud de Bogotá.

Interobserver agreement in the interpretation of anal intraepithelial neoplasia

Anal carcinoma incidence is increasing, and is highest among men with human immunodeficiency virus (HIV) infection who have sex with men. Anal carcinoma and anal intraepithelial neoplasia (AIN) are ascertained on tissue histology, but requires invasive procedures. Screening for AIN using anal cytology was suggested. The authors evaluated agreement on cytologic and biopsy specimens from HIV-positive men undergoing anal carcinoma screening. One hundred twenty-nine HIV-positive men with a history of anal-receptive intercourse underwent anal cytology, anoscopy, and biopsy. Four pathologists independently assessed cytology and biopsy specimens and reached consensus for discordant cases. Each pathologist evaluated 120 cytology and 155 biopsy specimens. The weighted kappa value for overall agreement was 0.54 (95% confidence interval [CI], 0.49-0.59) for cytology specimens and 0.59 (95%CI, 0.55-0.63) for biopsy specimens. The median kappa values for pairwise agreement among pathologists and for agreement with consensus were, respectively, 0.69 and 0.77 for cytology and 0.66 and 0.75 for biopsy. At least 3 pathologists were in agreement for 92 (76.7%) cytology and 134 (86.5%) biopsy specimens. Reliability for the Bethesda classification system was at least moderate, except for the cytologic category of atypical squamous cells of undetermined significance (kappa = 0.12). Fourteen of 29 (48.3%) cytology specimens and 36 of 47 (76.6%) biopsy specimens with consensus interpretation of high-grade squamous intraepithelial lesions (HSIL) were interpreted originally as HSIL by > or = 3 pathologists. The kappa value for agreement with consensus distinguishing HSIL from non-HSIL ranged from 0.55 to 0.88 for cytology specimens and from 0.76 to 0.94 for biopsy specimens. Agreement for cytologic and biopsy interpretations was generally at least moderate. Nevertheless, these results supported the need for disease indicators with greater reliability.

Anal cytology is a poor dysplasia screening test for patients with anal condyloma

Condyloma acuminatum is the most common sexually transmitted disease affecting 10–15 million individuals, with 2–3 million new cases diagnosed annually. Anal condyloma are frequently managed by surgeons. Biopsy and histologic evaluation is required to grade dysplasia. High-grade dysplasia may progress to carcinoma. The purpose of this study was to determine whether anal cytology is an effective noninvasive method to detect high-risk anal condylomas. Methods. All patients with anal condylomas were prospectively evaluated with multiple biopsies and brush/swab cytology from September 2003 to April 2004. Histology and cytology were reported for each patient according to the Bethesda classification system and labeled as high or low grade. Pathologist and cytopathologist were blinded to all results. Results. Forty patients were enrolled. Histology showed 17 patients with high-grade and 23 with low-grade dysplasia. Table 1 shows the results of anal cytology testing compared to histopathology (gold standard). High-grade dysplasia was positively identified by anal cytology in 6 of 17 patients (sensitivity 35%). When anal cytology was read as low grade, 22 of 33 patients had histologically verified low-grade lesions, while 11 had high-grade dysplasia (negative predictive value 66%). Conclusion. Anal cytology has poor sensitivity and low negative predictive value for detecting high-grade dysplasia in patients with anal condylomas. Therefore, anal brush/swab cytology is not an effective screening tool to identify patients with condylomas that are high risk for developing carcinoma. TABLE—ABSTRACT 44 Dysplasia screening Histology Cytology High grade Low grade High grade 6 1 Low grade 11 22

The Relationship Between Atypical Glandular Cells of Undetermined Significance on Pap Smear and a Clinically Significant Histologic Diagnosis

Objective: To determine whether the cytologic diagnosis of atypical glandular cells of undetermined significance (AGUS) on Pap smear was associated with a clinically significant histologic diagnosis.Methods: A retrospective cohort study was performed on the charts of women diagnosed with AGUS on Pap smear in 2 referral colposcopy clinics, between January 1999 and July 2002. The factors considered included age, menstrual status, use of birth control pills or hormone replacement therapy, parity, referral Pap, type of evaluation at colposcopy, histologic diagnosis, and final diagnosis at pathology.Results: Of the 124 women with a referral diagnosis of AGUS, 41 (33.1%) had significant histology at colposcopy. Premenopausal and nulliparous women were more likely to have a significant histologic diagnosis. The categories of “favour neoplastic” and “favour reactive” were not predictive of significant histology. Menopausal status was not predictive of either endometrial or endocervical disease among serious lesions.Conclusions: Because almost one-third of women with the finding of AGUS on Pap smear will have a diagnosis at the time of colposcopy that requires treatment, a colposcopy and endocervical curettage should be recommended to all women with AGUS. The new designation of “atypical glandular cells” (AGC) under the 2001 Bethesda classification system is appropriate, as “favour reactive” and “favour neoplastic” are not predictive of serious histologic findings.

Thin-layer liquid-based cervical cytology and PCR for detecting and typing human papillomavirus DNA in Flemish women.

The objective of this study was to document the occurrence and to correlate the prevalence of different human papillomavirus (HPV) types with the cytological results on simultaneously performed thin-layer preparations in a large population of Flemish women. During 1 year, 69 290 thin-layer preparations were interpreted using the Bethesda classification system. Using an algorithm for HPV testing based on consensus primers and type-specific PCRs in combination with liquid-based cytology, we determined the occurrence and distribution of 14 different oncogenic HPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68). Reflex HPV testing was performed on cytologically abnormal samples and on an age matched randomly selected control group with normal cervical cytology (n=1351). Correlation between cytology, age and prevalence for the 14 different high-risk HPV types is given. There is a significant increase in predominance of high-risk HPV types, with increasing abnormal cytology. Coinfection with multiple HPV types also increased with cytological abnormalities, and was highest in HSIL (16.7%). In Flanders, HSIL was most often associated with HPV types 16, 33, 35, 31, 18 and 51. Using thin-layer liquid-based cytology and PCR to detect HPV, it is feasible to screen large numbers of women.

Can glandular lesions be diagnosed in pap smear cytology?

Many reports have been published on the accuracy of the cervical vaginal smear for squamous lesions, and the literature contains fewer reports on the accuracy of the cervical vaginal smear for glandular lesions. The sensitivity of glandular lesion diagnosis depends on the subtype of lesion. The diagnostic sensitivity is highest for invasive endocervical adenocarcinoma and lowest for endometrial adenocarcinoma. The ability of some of the Bethesda system categories for glandular lesions to describe what they purport to describe is questionable. The Bethesda system categories of adenocarcinoma accurately classify adenocarcinomas. The Bethesda System category of atypical glandular cells of undetermined significance (AGUS) is a misnomer. Although many cases of adenocarcinoma in-situ are placed in this category, follow-up of patients with AGUS show that the majority of patients with clinically significant lesions have squamous dysplasias. Other categories of AGUS, such as AGUS favor endometrial origin, are more appropriately named and encompass endometrial lesions which are either neoplastic or non-neoplastic.

Atypical glandular cells of undetermined significance in cervical cytologic findings

Objective: Our purpose was to increase our understanding of the clinical significance of atypical glandular cells of undetermined origin. Study Design: All cytologic Papanicolaou smears were reviewed and classified within the context of the Bethesda classification system. Charts of all patients with a diagnosis of atypical glandular cells of undetermined origin were reviewed for previous medical history, diagnostic study, histologic diagnosis, and prior Papanicolaou smear abnormalities. Results: The incidence of atypical glandular cells of undetermined origin in 76,018 Papanicolaou smears was 0.196%. We reviewed 133 patient medical records with cytologic diagnoses. Eighty of these patients have had appropriate follow-up. Thirty-six (45%) of these were found to have significant histologic abnormalities, including 6 patients with cervical intraepithelial neoplasia, grades 2 and 3, and 4 invasive cancers. Conclusion: The frequency of underlying serious histologic changes is much greater in atypical glandular cells than in atypical squamous cells of undetermined significance. On the basis of our results, we believe that all patients with atypical glandular cells should undergo intensive evaluation including colposcopy, cervical biopsy, and endocervical curettage. When diagnosis cannot be clearly established, patient should undergo endometrial biopsy. (Am J Obstet Gynecol 1999;180:883-8.)

The effect of route of delivery on regression of abnormal cervical cytologic findings in the postpartum period

OBJECTIVES: We sought to determine whether pregnant women with abnormal antepartum cervical cytologic findings differ in their postpartum rates of regression with respect to mode of delivery. STUDY DESIGN: Between 1990 and 1997, 446 pregnant women with antepartum abnormal cervical cytologic findings were identified. Complete demographic, clinical, and cytologic reports were available for 138 women. Papanicolaou smear data were collected and separated into three groups by use of the Bethesda classification system (atypical squamous cells of undetermined significance, low-grade squamous intraepithelial cells, and high-grade intraepithelial cells). Postpartum regression rates of antepartum Papanicolaou smears, with respect to degree of squamous epithelial cell abnormality and mode of delivery, were analyzed by Fisher's exact and Wilcoxon rank sum tests. RESULTS: Of the 138 women, 109 (79%) were delivered vaginally and 29 (21%) by cesarean section. No statistically significant difference was found between women delivered vaginally and those delivered by cesarean section with respect to age, parity, and smoking history within the three groups (atypical squamous cells of undetermined significance, low-grade squamous intraepithelial cells, and high-grade squamous intraepithelial cells). The overall postpartum regression rate for the 59 women with antepartum high-grade squamous intraepithelial cells was 48%. Of the 47 women with high-grade squamous intraepithelial cells who were delivered vaginally, 28 showed regression in the postpartum period versus none of the 12 women delivered by cesarean section (60% vs 0%, p < 0.0002). CONCLUSION: Postpartum spontaneous regression of Papanicolaou smears consistent with high-grade squamous intraepithelial cells occurs with increased frequency among women who are delivered vaginally versus by cesarean section. (Am J Obstet Gynecol 1998;178:1116-20.)

The Value of Repeat Pap Smear at the Time of Initial Colposcopy

Abstract Objective. The objective was to determine if repeating a Pap smear at the time of an initial colposcopy has sufficient clinical benefit to justify its clinical and financial costs. Methods. The records were reviewed of all patients who had an initial colposcopy at Queens Hospital Center between 1984 and 1995. Data were gathered regarding the referral cytology, the cytology done at the time of colposcopy, and the results of any biopsies which were taken. The terminology for cytology and histology done prior to 1989 was adjusted to the Bethesda classification system. A repeat Pap smear was defined as clinically valuable if it would have changed the patient's management, i.e., if it suggested more advanced disease than the referral Pap and that the disease was not identified on the colposcopically directed biopsy. Results. Two thousand nine hundred sixty-nine records were reviewed. In 139 cases, no Pap smear was repeated at the time of colposcopy. Of the remaining 2830 women, only 1347 (47.6%) showed exact correlation between their referral Pap smear and the Pap done at the time of colposcopy. In another 1016 (35.9%), the Pap at colposcopy was within one grade of the referral Pap. In 312 women, the Pap at the time of colposcopy was a higher grade than the referral Pap. However, in 236, the higher grade of disease was detected by the colposcopically directed biopsy. Of the remaining 76 women, 58 had a normal biopsy, but their Pap at the time of colposcopy showed low-grade squamous intraepithelial lesions (44) or high-grade squamous intraepithelial lesions (HGSIL) (14). Seventeen others had a biopsy showing low-grade dysplasia while the Pap at the time of colposcopy showed HGSIL. In 1 patient, the repeat Pap showed malignant cells while the biopsy showed a high-grade lesion. Based on the triage protocols at our institution, this means that a repeat Pap at the time of colposcopy would have indicated a cone biopsy in 31 patients (1.1%) and more careful follow-up of another 44 patients (1.6%). Skipping the repeat Pap smear would not have resulted in any missed cancers. In our series of 2830 patients, the cost savings of skipping the repeat smear would have been $68,580 or $24.23 per patient. On a national level, skipping the repeat smear would save more than $24,000,000 annually. Conclusion. Using current triage protocols at our institution, repeating the Pap smear at the time of an initial colposcopy would have changed the management in 2.7% of patients and indicated a conization in only 1.1% of patients. It is doubtful that this justifies its cost and the potential detrimental effects on the colposcopic examination.

Stanley F. Patten, Jr., M.D., Ph.D. and the development of an automated Papanicolaou smear screening system.

Stanley F. Patten, Jr., M.D., Ph.D. and the development of an automated Papanicolaou smear screening system.