Routine Cervical Cytology Research Articles

Surgical Management of Early Invasive Cancer of the Cervix Associated with Pregnancy

The simultaneous occurrence of carcinoma of the cervix in pregnancy is uncommon. In a prospective study of 397 patients undergoing type III radical hysterectomy for early invasive cancer of the cervix, 18 were pregnant at the time off surgery; 4 of these were operated after delivery elsewhere. Two others had a type I extrafascial hysterectomy. The incidence was 1 in 4077 deliveries. The clinical and histological characteristics of these patients are presented. Routine speculum examination and cervical cytology in all pregnant patients early in pregnancy are vital for early diagnosis. Bleeding in pregnancy should not automatically be assumed to be caused by pregnancy-related conditions. The strategies in surgical management are discussed. Radical hysterectomy in pregnancy is safe. No major complications were encountered; the mean blood loss was 1.4 liters. The incidence of pelvic node metastases was similar to that seen in nonpregnant patients. The overall 5-year survival rate was 77.7%. Of the 4 patients who died, 3 presented in the puerperium; all succumbed within 27 months. Poor histological prognostic features contributed to the significantly poorer survival in the puerperal patients ( P = 0.0445). The 5-year survival in those presenting during the antepartum period (92.8%) was, however, similar to that in the nonpregnant patients. Metastases to the placenta or fetus were not encountered.

Long term follow up of women with borderline cervical smear test results: Effects of age and viral infection on progression to high grade dyskaryosis

OBJECTIVE--To follow up and assess the significance of borderline change in cervical smears. DESIGN--Retrospective study of women undergoing routine cervical cytological screening in 1981. SETTING--Avon Cervical Screening Programme, covering 250,000 women in Bristol and Weston super Mare. SUBJECTS--437 women showing borderline cervical changes in 1981 and 437 age matched controls with normal results in 1981. MAIN OUTCOME MEASURES--Cytological progression to high grade dyskaryosis (cervical intraepithelial neoplasia grade III or invasive carcinoma). RESULTS--During follow up ranging from 13 to 106 months 98 of the 437 women (22.4%) with borderline cytological changes on routine cervical cytology screening had a subsequent smear test showing high grade dyskaryosis compared with three of the 437 women (0.9%) in the control group. The risk of progression was greater in women aged 20 to 39 than in those aged 40 and over. Human papillomavirus infection had initially been diagnosed cytologically in 101 of the 437 (23%) women with borderline results. Significantly fewer of these women developed high grade dyskaryosis (13/98 (13%) v 88/339 (26%), p less than 0.05). CONCLUSIONS--Women with borderline smear test results are at increased risk of developing high grade dyskaryosis, particularly if the borderline changes occur without cytological features of human papillomavirus infection. Progression occurs within three years in 50% of cases, although a linearly increasing risk was sustained over the nine years of follow up and was greatest in women aged 20 to 39. Careful follow up of these women is indicated.

Long term follow up of women with borderline cervical smear test results: effects of age and viral infection on progression to high grade dyskaryosis.

To follow up and assess the significance of borderline change in cervical smears. Retrospective study of women undergoing routine cervical cytological screening in 1981. Avon Cervical Screening Programme, covering 250,000 women in Bristol and Weston super Mare. 437 women showing borderline cervical changes in 1981 and 437 age matched controls with normal results in 1981. Cytological progression to high grade dyskaryosis (cervical intraepithelial neoplasia grade III or invasive carcinoma). During follow up ranging from 13 to 106 months 98 of the 437 women (22.4%) with borderline cytological changes on routine cervical cytology screening had a subsequent smear test showing high grade dyskaryosis compared with three of the 437 women (0.9%) in the control group. The risk of progression was greater in women aged 20 to 39 than in those aged 40 and over. Human papillomavirus infection had initially been diagnosed cytologically in 101 of the 437 (23%) women with borderline results. Significantly fewer of these women developed high grade dyskaryosis (13/98 (13%) v 88/339 (26%), p less than 0.05). Women with borderline smear test results are at increased risk of developing high grade dyskaryosis, particularly if the borderline changes occur without cytological features of human papillomavirus infection. Progression occurs within three years in 50% of cases, although a linearly increasing risk was sustained over the nine years of follow up and was greatest in women aged 20 to 39. Careful follow up of these women is indicated.

Detection of Cervical Human Papillomavirus by Molecular Probes

To the Editor.— Genital infection with human papillomavirus (HPV) is a matter of concern because of its increasing prevalence and because some types of the virus may be oncogenic. We have studied the prevalence of HPV infection in women having routine cervical cytology in the family planning clinic at Women's Hospital, Los Angeles County-University of Southern California Medical Center. Four hundred forty-two women had cervical scrapings taken for cytological examination and HPV detection. The mean age was 27.2 years, and 95% of the subjects were Hispanic. Viral DNA was extracted from cervical cells, bound to nylon membranes, and identified by its reaction with a mixture of radiolabeled RNA probes specific for HPV types 6 and 11,16 and 18, and 31,33,35 (Human Papillomavirus DNA Detection Kit, Virapap; Life Technologies, Inc, Gaithersburg, Md, 1987).1Positive samples were typed with group-specific probes for these viral types (Human Papillomavirus DNA Typing Kit, Viratype;

Should the Cytobrush® be used in routine screening for cervical pathology?

In 632 women visiting a family planning clinic, paired cervical smears were taken using a wooden spatula and a Cytobrush R. Of the spatula smears 7.8% were unreliable with too little or scanty material to allow a cytologic diagnosis (class 0); 17.7% of spatula smears were inadequate, lacking endocervical cells. Combined spatula/Cytobrush R cytology reduced these figures significantly; 4.3% unreliable smears and 3.2% inadequate specimens. Seventy-three (11.6%) of the smears revealed some abnormality, in most cases Papanicolaou class IIIA, suggestive of mild dysplasia. In 10 cases, dysplastic cells were found only in the Cytobrush R cytology. It is concluded that the Cytobrush R adds to the improvement of smear quality and the accuracy of routine cervical cytology obtained by relatively inexperienced smear takers.

Cervical cytology screening in a sexually transmitted diseases clinic for the first time in Sri Lanka.

A prospective study of cervical cytology was carried out on 350 consecutive female patients attending the central venereal diseases clinic (CVDC) in Colombo, Sri Lanka. The main objective was to assess the proportion of abnormal cervical smears to emphasise the need to introduce routine cervical cytology screening in the sexually transmitted diseases (STD) clinics in Sri Lanka. Data about each woman's age, sexual history, method of contraception, number of pregnancies, genital infections, and previous cervical smears were collected to compare the findings in patients with normal smears with findings in those with abnormal smears. Smears reported as showing koilocytic atypia, dyskaryosis, carcinoma in situ, or invasive carcinoma were considered to be abnormal. Forty seven (13.4%) women in the study sample had abnormal smears, and 32 of these were aged under 35. None of the 350 patients had had a cervical smear taken previously. Women who had had five or more pregnancies, compared with those who had had four or fewer pregnancies, and women with trichomoniasis, compared with no genital infection, had significantly higher incidences of abnormal than normal smears. Higher proportions of abnormal than normal smears were also found in women whose sexual partners had been surgically sterilised. These findings suggest a serious need for cervical cytology screening in STD clinics.

Routine Colposcopy and Cytology During Pregnancy for Detection of Cervical Premalignant and Malignant Lesions

Routine cervical cytology and colposcopy were done in 500 successive pregnant females. In 29 (5.9%), colposcopically abnormal areas were found on the cervix, 4 outside and 25 within the transformation zone (TZ). Colposcopically directed biopsies from these areas revealed acanthotic epithelium in the 4 cases outside the TZ and in 13 cases within the TZ (52% of cases), chronic cervicitis in one (4%), and cervical intraepithelial neoplasia (CIN) II or III in 13 (44%); in other words, the false positive colposcopy rate was 56%. However, all cases with acanthotic epithelium showed minor colposcopic changes, namely, leukoplaskia, finely punctated or mosaic-like and faint, unraised acetowhite areas. The number of colposcopically directed biopsies could have been reduced by more than 50% if biopsy was taken from areas that showed such major colposcopic findings as coarse punctation and mosaic patterns, atypical vessels, or intense white and raised acetowhite areas. Routine Papanicoleau smear revealed dyskaryotic cells in 10 women (20% of cases), which were diagnosed as mild in 3, moderate in 5, and severe in 2. Of these cases, 8 showed CIN; in other words, the false positive cytology rate was 20%. In the 11 women with histologically proven CIN, Pap smear revealed dyskaryotic cells in 8 (72.2%); in other words, the false negative cytology rate was 27.3%.

The cost of saving a life through cervical cytology screening: implications for health policy

Through a review of the published literature on routine cervical cytology screening, this paper seeks to establish a likely range for the cost of saving a life through this screening programme as presently organised in England and Wales. The current performance of the programme may be expressed in several ways: a cost of £270000 to £285000 per life saved, 40000 smears and 200 excision biopsies per death averted, or 1000 to 1500 avoidable deaths annually in England and Wales alone. The policy problems are thus of two kinds. First, there is a substantial misallocation of the limited resources available to an insurance based system of health care. Further, the money which is spent on this service does not avoid the mortality and morbidity which could reasonably be expected if the system were performing adequately. It is suggested that substantial improvements in the performance of the programme may well be possible if managers are appointed. Nevertheless a deeper policy issue is raised: to be delivered efficiently, any service based on population rather than individual considerations will require some acceptance by the medical profession of a limit to their traditional view of clinical freedom. The unresolved clash between population and individual considerations which poses such a fundamental challenge for policy making in insurance based health services is particularly well illustrated by the dilemma of publicly funded cervical cytology screening.

High prevalence of cervical dysplasia in STD clinic patients warrants routine cytologic screening.

The results of routine cervical cytology screening at a Planned Parenthood Center (PPC) clinic were compared to those at a nearby sexually transmitted diseases (STD) clinic in Seattle. Cervical cytologic findings were consistent with cervical intraepithelial neoplasia (CIN), grades 1 (mild dysplasia), 2 (moderate dysplasia), or 3 (severe dysplasia to carcinoma in situ) in 502 (5.9 per cent) of 8,504 PPC patients and 87 (11.4 per cent) of 764 STD patients (p = .001). This rate for STD patients is five times that reported for the general population. Sixty-three PPC patients and 31 STD patients with screening smears consistent with CIN 1 or 2 underwent further prospective study by us, including repeated cytologic and colposcopic examinations. Thirty-seven (59 per cent) of 63 PPC patients and 26 (84 per cent) of 31 STD patients (p = .02) had at least on additional smear or colposcopy consistent with CIN and were advised to undergo cervical biopsy. Among those who underwent recommended biopsy, CIN was confirmed histologically in 15 (50 per cent) of 30 PPC patients and 11 (61 per cent) of 18 STD patients. Thus, the proportion of patients who had screening cytologic findings consistent with CIN, the proportion with persistent cytologic or colposcopic findings consistent with CIN on retesting, and the proportion of those biopsied who had histologically confirmed CIN, all were higher for STD than for PPC patients. There is a serious need for cytologic screening in STD clinics throughout the nation.

Aspects of student health. Adolescent gynaecology.

Most adolescent gynecological problems are related to sexual activity or the development or failure of hypothalamic-pituitary-ovarian-uterine activity. The 1st years of menstruation are usually anovulatory resulting in variable periods of amenorrhea which corrects itself in time. In profuse menstrual loss, endocrine, metabolic, and hemorrhagic disorders must be exlcuded before treatment with progesterone for endometrial hyperplasia. Primary amenorrhea requires detailed examination before diagnosis. Secondary amenorrhea is commonly caused by a disturbance of the hypothalamic-pituitary-ovarian axis due to an emotional disturbance. If pregnancy is eliminated, examination and reassurance are sufficient treatment. Most dysmenorrhea may be treated with mild analgesics and reassurance; in severe cases ovulation may be inhibited by estrogen treatment. Dilation of the cervix should never be attempted. In complaints of vaginal discharge, examination should be made for trichomonas, monilia, gonorrhea, or a forgotten tampon. Requests for contraception should be taken seriously regardless of age. The combined contraceptive pill or Gravigard or copper 7 IUD is the method of choice. Lower abdominal pain caused by pelvic inflammatory disease should be treated early to prevent tubal occlusion after salpingitis. Evidence of higher cervical cancer incidence among women who were sexually active in adolescence suggests routine cervical cytology should be performed. Treatment of adolescents should dispel ignorance and embarrassment with patience and skill.

CERVICAL CYTOLOGY CONSENT RATE

In a large-scale computer-assisted population screening programme undertaken in West Sussex, 72.5% of women, mainly under the age of 70 years, consented to have routine cervical cytology and breast examinations.

Value of routine cervical and vaginal cytology in gynecological patients in order to detect tumour cells.

Value of routine cervical and vaginal cytology in gynecological patients in order to detect tumour cells.

Detection of unsuspected cervical cancer by cell study

1. 1. Two cases of early carcinoma of the cervix, which were diagnosed by routine selective cervical cytology smears, are presented. 2. 2. Clinical Judgment is not sufficient grounds upon which cancer of the cervix can be ruled out. The most innocent-appearing cervix may be the seat of a silent, but active, cancer. 3. 3. The pathologist can report only what he sees. Unless the tissue sent to the laboratory contains the cancer, the pathologist cannot be expected to make the diagnosis. 4. 4. In preclinical lesions the common practice, on the part of men unskilled in intravaginal manipulations, of using the biopsy punch to obtain a single tiny bit of tissue provides an inferior specimen and leads to false impressions. 5. 5. The single surgical specimen is better, but a single bit of tissue may miss the lesion. 6. 6. Multiple biopsy specimen method is still better, but this is not a practical procedure. We cannot expect the practitioner to admit to the hospital every one of his female patients to have this procedure carried out. Yet how is one to pick out the suspicious cases? The selective cervical cytology test performs this function. 7. 7. The basic principles of the cytology test and the various methods of taking the smears are briefly described. 8. 8. Reasons are given for our belief that the cervical modification of the test is superior to the original vaginal smear technic. 9. 9. The advantages of the cervical cytology test as a routine procedure are listed. 10. 10. A case with positive cytology deserves a complete investigation including, if necessary, cervical amputation followed by serial sectioning as well as curettage of the fundus. 11. 11. Stress is laid on the importance of cooperation and teamwork among the various members of the profession if we are to achieve the goal of finding cancer of the cervix in an early curable stage.