Systemic and pulmonary diseases that affect the pleura are usually characterised by accumulation ... more Systemic and pulmonary diseases that affect the pleura are usually characterised by accumulation of fluid in the pleural cavity or by fibrous healing of damaged mesothelium. Some of the reactive changes THE The mesothelial cells form a complete layer of cells 176
Summary This article provides an illustrated personal view of the British Society for Clinical Cy... more Summary This article provides an illustrated personal view of the British Society for Clinical Cytology's (BSCC) proposal to modify their terminology for reporting cervical cytology. The BSCC did not propose any major changes but moved closer to the two-tier Bethesda system for reporting pre-cancerous changes as high-grade and low-grade. Certain principles of reporting cytology that were intended in the original BSCC terminology are reinforced and difficult areas of borderline nuclear change are clarified. Revisiting the old terminology has drawn attention to errors and omissions in existing descriptions of dyskaryosis; this term is still used although its definition has been refined. This article will describe and illustrate different manifestations of dyskaryosis, with emphasis on its recognition as such, and its distinction from a wide variety of reactive changes. The illustrations draw widely on one of the author's (LT's) extensive experience with both types of liquid-based cytology preparations, which will now be the predominant methods of cell preparation in the UK.
To audit the use of the ThinPrep Imaging System (TIS) for internal quality control (IQC) in the p... more To audit the use of the ThinPrep Imaging System (TIS) for internal quality control (IQC) in the place of rapid review (RR), and to compare its performance with routine primary screening. During 9 months, 16 462 ThinPrep slides were processed by TIS. Slides were initially reviewed using the TIS review scope, as recommended by the manufacturer: 22 fields of view were observed and, if considered abnormal, a full microscopic review was conducted using the review scope. Different biomedical scientists (BMSs), working on each procedure in rotation, performed batches of TIS-assisted quality control and routine primary screening independently on unmarked slides. Any slides with abnormalities detected by either method were referred to a consultant pathologist or advanced BMS practitioner for a final report. TIS results were compared with both previous records of RR and routine primary screening carried out on the same slides. We used the UK terminology in which 'dyskaryosis' is equivalent to squamous intraepithelial lesion (SIL) and borderline to atypical (including squamous and glandular cells). TIS preview detected significantly more high-grade dyskaryosis compared with RR during the previous 4 years: 2.0-4.2 compared with 0.1-1.8 detected per 1000 slides (P = 0.0001). TIS and routine screening were equivalent in sensitivity and specificity for the final cytology result, but BMSs were significantly more likely to classify slides as dyskaryotic rather than borderline when using TIS compared with routine screening. Referrals for potentially high-grade abnormalities detected by TIS-assisted IQC alone found 28 biopsies of at least cervical intraepithelial neoplasia grade 2 (CIN2+), whereas 15 CIN2+ biopsies were found on routine screening but missed using TIS. There was no significant change in the rates of inadequate tests, high- or low-grade cytological abnormalities, or positive predictive value for CIN2+ when TIS was in use. Screening with TIS was more sensitive than RR for IQC, providing a rescreening method equivalent to routine primary screening in overall accuracy.
Introduction The aims of this study were (i) to assess the use of Hybrid‐capture II (HCII) along... more Introduction The aims of this study were (i) to assess the use of Hybrid‐capture II (HCII) alongside conventional cytology for triage of mildly abnormal smears and (ii) to establish the local prevalence of high‐risk human papillomavirus (HRHPV).Study design In an on‐going study, 669 women aged 20–50 were recruited into (i) a study group, with current abnormal cytology or a history of previous abnormal cytology and (ii) an anonymous control group with current negative cytology and no history of abnormal smears. HCII positive was used as a surrogate for mild dyskaryosis in women with negative smears in the study group.Results There was strong correlation between positive HCII tests with degree of cytological abnormality. HCII was positive in 13 of 13 (100%) of women with at least moderate dyskaryosis, 27 of 34 (79%) with mild dyskaryosis, 18 of 36 (50%) with borderline abnormalities, 36 of 250 (14%) of negative smears. In the control group, 50 of 308 (16%) of negative smears were p...
Are significant numbers of abnormal cells lost on the discarded ThinPrepÒ broom when used for cer... more Are significant numbers of abnormal cells lost on the discarded ThinPrepÒ broom when used for cervical cytology? Background: In view of a study with SurePathÒ showing that cells were lost on the broom if it was discarded, we decided to investigate whether cells were lost on the ThinPrepÒ (TP) broom, which is discarded according to the manufacturerÕs protocol. Aim: To determine whether significant amounts of cellular material are lost on the discarded TP broom, and whether the loss is operator dependent. Methods: Three hundred and six women attending the GuyÕs Hospital Colposcopy Unit gave their consent for TP liquid-based cytology samples to be taken and the broom immersed in a second vial instead of being discarded. The cellularity of the first and second vials was compared by counting cells in 10 •40 high-power fields (HPFs). The significance of cell loss was ascertained by correlating the likelihood of abnormal cells and transformation zone (TZ) material being present with the degree of cellularity of the two vials. Results: More than 10 cells per HPF were seen in 3.2%, 19.4% and 35.8% of slides from the second vial taken by three experienced colposcopists, which was significantly different between them (P < 0.001); cellularity of the first vial was not significantly different between colposcopists but the one with highest cellularity in the first vial discarded most in the second. Abnormal cells were more likely to be seen in slides with more than 10 cells per HPF (P < 0.001) and with evidence of TZ sampling (P < 0.001), but there was no preferential loss of TZ material in the second vial. Of 126 slides with abnormal cells on the slides from the second vial, 113 (89.7%) were also present on the significantly more cellular first vial (P < 0.001). Conclusion: Abnormal cells were potentially lost on the broom, but were usually represented in the first vial. The likelihood of abnormal cells being discarded was operator dependent in this small study, but this did not affect the quality of the initial preparation. The likelihood of abnormal cells being seen on TP slides was dependent on their cellularity, which provided our laboratory with a criterion for the assessment of sample adequacy.
Opinions about cervical screening in the UK tend to follow one of two negative lines of thought. ... more Opinions about cervical screening in the UK tend to follow one of two negative lines of thought. The first is that cervical cancer is a rare disease, and too much time and effort are spent on screening. The second is that it has been relatively ineffective, since incidence of invasive carcinoma did not fall until the NHS Cervical Screening Programme (NHSCSP) was introduced in 1988, although it fell by 40% since then. This paper presents publicly available data to demonstrate that neither of these views is true. Registrations of invasive carcinoma of the uterine cervix and carcinoma in situ in England and Wales between 1971 and 1996 show that a substantially increased risk of disease in women born since 1940 has been reversed, almost certainly by greatly improved screening. Cervical carcinoma is now a rare disease because most cases are prevented before they become invasive, mostly by screening young women, aged 20–40, before the decade of life when symptomatic cervical carcinoma mos...
In a 12-year study of the population of Southampton and South-west Hampshire (SSWH), there was no... more In a 12-year study of the population of Southampton and South-west Hampshire (SSWH), there was no rise or fall in the incidence of adenocarcinoma of the uterine cervix, although the incidence of squamous cell carcinoma fell from 14 to 7.2 per 100000 women years and the overall fall in age-adjusted incidence of cervical carcinoma was commensurate with that of England and Wales. The majority (59%) of adenocarcinomas were seen in women aged less than 50, supporting the concept of a higher risk in young women. Screen-detected carcinomas accounted for 50% of adenocarcinomas and 41% of squamous cell carcinomas in women aged 20-64 (the difference was not significant). There were more screen-detected adenocarcinomas of less than 3 mm depth of invasion and 7 mm lateral extension during the third period of the study (1991-1993). The results are consistent with reports of an increased risk of cervical cancer in women born since 1940, and lesser effectiveness of screening in preventing adenocarcinoma compared with squamous cell carcinoma. High prevalence of early screen-detected carcinomas may have been a factor in recent reports of increased incidence of adenocarcinoma.
In this issue of Cytopathology we publish an extensively referenced review article by Austin and ... more In this issue of Cytopathology we publish an extensively referenced review article by Austin and Zhao describing types of cervical cancer that may not be prevented by screening. The authors describe four such types, frequently seen in medicolegal practice, which they categorize collectively as Type 2 cancers: (i) rapidly progressive carcinomas, (ii) carcinomas arising in younger women (in their 20s and 30s), (iii) carcinomas with glandular differentiation and, perhaps more surprisingly, (iv) carcinomas arising in older (postmenopausal) women. Individually these types of carcinoma are rare, but they have become relatively more frequent as regular screening has prevented the majority of cervical cancers in the populations at risk. Also in this issue of Cytopathology, Castanon et al. publish the results of a multicentre cervical cancer audit, with cytology and histology slide review, in the National Health Service Cervical Screening Programme (NHSCSP) and Repše-Fokter et al. report a similar audit of a relatively new but demonstrably successfully organized screening programme in Slovenia. How should the inevitability of false-negative tests be reconciled with public and professional expectations of cancer prevention, while simultaneously avoiding unnecessary investigation and the treatment of young women of childbearing age? False negatives may occur at any stage of the screening process from collecting the sample to colposcopy, and in any type of test. Slides look different in retrospect when the outcome of cancer is known – as recognized by the authors of both cancer audits. Even biopsies may look different in retrospect. Castanon et al. found that of biopsies reported before the eventual diagnosis of cancer as negative, cervical glandular intraepithelial neoplasia (CGIN) or cervical intraepithelial neoplasia (CIN) grade 3, 1%, 15% and 12% respectively were upgraded to cancer on review. In the same audit, 23% of cytology slides reported as negative during the 10 years before diagnosis of cancer were upgraded to high-grade dyskaryosis as were more than half of those originally reported as low grade. Repše-Fokter et al. upgraded 17 out of 33 smears that had been reported as negative, low grade or inadequate within the previous screening round in 42% of all women with cancer. It can be difficult to explain to noncytologists that small, scarce, pale dyskaryotic cells may occasionally be missed and that a single cytology sample may not be representative of an abnormality. Such cases are quite likely to result in litigation because, according to Austin and Zhao, they are disproportionately seen in interval cancers in previously screened women. Cancer audits by their nature review screening histories and slides in women who subsequently develop cancer but Farnsworth, discussing quality control of a highly successful screening programme in Australia, reminds us that women with high-grade CIN have often had previous negative tests. Of women with high-grade lesions on histology, 22% had negative cytology and 13% had negative human papillomavirus (HPV) tests within the previous 30 months. A previous negative test does not negate the value of detecting high-grade CIN on a subsequent test. In well-screened populations, increasing percentages of cancers are in previously screened women, screen-detected and in younger age groups. Incidence of invasive cervical cancer in England has been highest in women aged 30–34 since 2004, but is also increasing in those aged 25–29 and 35–39: by 2009 45% of all cervical cancers were in women in their 20s and 30s (calculated from Office for National Statistics registrations). As Marshall and Zhao point out, cancers in younger women can be difficult to prevent. In an audit carried out at Guy s & St Thomas , two-thirds of women aged 20–34 with cancer had been screened during the previous 5 years, and twothirds in that age group had screen-detected 1A or 1B1 cancers (83.3% of women aged 20–29). RepšeFokter et al. observed that cancers in previously screened women were often diagnosed at an early stage after recent high-grade cytological abnormalities. Just like high-grade CIN, early cancers may not be found on the first test; but that does not negate the clinical value of detecting them on a subsequent test. Aggressive cancers without extensive CIN3 and adenocarcinomas may explain some genuine false negatives that remain negative on review. False negatives as a consequence of abnormalities missed on cytology are an important focus for quality control
Anshu, A. Herbert, B. Cochand‐Priollet, P. Cross, M. Desai, R. Dina, J. Duskova, A. Evered, A. Fa... more Anshu, A. Herbert, B. Cochand‐Priollet, P. Cross, M. Desai, R. Dina, J. Duskova, A. Evered, A. Farnsworth, W. Gray, S. S. Gupta, K. Kapila, I. Kardum‐Skelin, V. Kloboves‐Prevodnik, T. K. Kobayashi, H. Koutselini, W. Olszewski, B. Onal, M. B. Pitman, Ž. Marinšek, T. Sauer, U. Schenck, F. Schmitt, I. Shabalova, J. H. F. Smith, E. Tani, L. Vass, P. Vielh and H. Wiener Survey of medical training in cytopathology carried out by the journal CytopathologyThis report of the Editorial Advisory Board of Cytopathology gives the results of a survey of medical practitioners in cytopathology, which aimed to find out their views on the current situation in undergraduate and postgraduate training in their institutions and countries. The results show that training in cytopathology and histopathology are largely carried out at postgraduate level and tend to be organized nationally rather than locally. Histopathology was regarded as essential for training in cytopathology by 89.5% of respondents and w...
BJOG: An International Journal of Obstetrics & Gynaecology, 2009
To assess the clinical significance of screen-detected cancer compared with symptomatic cervical ... more To assess the clinical significance of screen-detected cancer compared with symptomatic cervical cancer during the introduction of organized screening. Screen-detected and symptomatic cancers were analysed according to International Federation of Obstetrics and Gynecology stage and histological type of cancer and age of women during four 3-year periods. Southampton and South West Hampshire (SSWH). Women resident in SSWH registered with invasive cervical carcinoma between 1985 and 1996. Screen-detected and symptomatic cancers were defined on the basis of clinical information obtained at the time of diagnosis and recorded together with date of diagnosis, age group, histology and cytology results. Data were held for analysis on an anonymous spreadsheet. Incidence of screen-detected and symptomatic cancers per 100 000 women; association between route to diagnosis, age group, stage of cancer and screening history during four 3-year periods. Of 382 cancers, 256 were symptomatic, 78 screen-detected fully invasive and 48 screen-detected microinvasive. Incidence of symptomatic cancers fell from 13.0 to 6.4 per 100 000 total female population (P = 0.0005), and there was a trend towards screen-detected cancers as a proportion of all cancers (P = 0.002). By the latest period of the study (1994-96), the likelihood of cancers being screen-detected was strongly associated with younger age groups (P = 0.001). Screen-detected fully invasive cancers were significantly less likely (P = 0.001) to be diagnosed at stage II or above (16.6%) compared with symptomatic cancers (63.3%). Women with screen-detected microinvasive cancers were significantly more likely (P &amp;amp;lt; 0.001) to have been screened within 5 years (83.3%) than screen-detected fully invasive cancers (60.2%) or symptomatic cancers (33.6%). Screen-detected cancers were more likely to be diagnosed at an earlier stage, in younger women and in women who had previously been screened and became relatively more frequent as symptomatic cancers declined.
sYNoPsis Fixation of lungs at necropsy by inflation with formaldehyde vapour was used in a combin... more sYNoPsis Fixation of lungs at necropsy by inflation with formaldehyde vapour was used in a combined radiological and pathological study of pulmonary oedema. Pulmonary oedema was found in 79 % of lungs examined. The earliest phases affect the interstitial tissue with oedematous connective tissue planes and distension of pulmonary lymphatics. These changes may be associated with reduction in the compliance of the lung. Alveolar filling is a late stage in the accumulation of oedema fluid in the lungs.
To establish a histological standard against which surgical biopsy material could be compared, th... more To establish a histological standard against which surgical biopsy material could be compared, the degree of mesothelial proliferation was studied in 100 unselected necropsies. A minor degree of mesothelial hyperplasia was identified in 10 cases, usually close to areas of fibrous adhesions. Pleural plaques were present in 33 patients but there was no evidence of associated mesothelial proliferation. No mesothelial changes were noted in patients with empyema or pleural metastases. These findings indicate that the degree of mesothelial hyperplasia in common disorders of the pleura is relatively slight. Significant mesothelial proliferation in needle biopsies should therefore be viewed with considerable suspicion and, where clinically appropriate, be followed by further investigation.
Nine primary malignant lymphomas of the lung are described. Seven were localized lesions, and two... more Nine primary malignant lymphomas of the lung are described. Seven were localized lesions, and two were diffuse bilateral infiltrations. Histopathologic examination of these lesions suggests that they represent examples of the same entity and that it is a malignant lymphoma rather than a reactive infiltration or &quot;pseudolymphoma.&quot; Histologic evidence of lymph node involvement is unusual, even in the presence of mediastinal or pleural infiltration. Immunohistochemical studies demonstrated a monotypic B-cell population in cases in which suitable tumor tissue was available for study (four of nine). Of the other five cases, two had a population of monotypic B lymphocytes in the peripheral blood, and in one of these and in one additional case gastric lymphomas subsequently developed. It is suggested that these lymphomas arise from bronchus-associated lymphoid tissue, which would explain both their histologic features and their tendency to remain localized to the lung for long periods.
Cytopathology : official journal of the British Society for Clinical Cytology, 2014
Jain and co-authors at the All India Institute of Medical Sciences (AIIMS), in the lead article i... more Jain and co-authors at the All India Institute of Medical Sciences (AIIMS), in the lead article in this issue of Cytopathology, explain the enormous advantages of cell blocks (CBs) as an adjunct to cytology. The authors also mention their limitations and the differences between methods; and they make the important point that CBs are ‘not a substitute but complementary to conventional cytology techniques’. Nevertheless, in practice CBs are sometimes used instead of cytology in centres where pathologists’ have less confidence in cytology. Seven years as editor of Cytopathology has led me, on looking back over publications in this journal, to reflect on why we need cytological preparations, why it has been said that ‘most pathologists are not interested in cytology’, and why training in cytopathology in the UK and elsewhere in Europe remains a problem. Medical and non-medical cytologists work closely together and depend on each others’ skill: principles for an extended role of cytotechnologists (CTs) discussed in the October issue of Cytopathology are also relevant to pathologists. These surveys and discussions include examples of good practice in other countries, such as the USA and Australia, to which this editorial refers. Cell blocks provide a method for immunocytochemistry (ICC) that has revolutionized cytopathology by making it possible to apply panels of antibodies to multiple sequential sections of aspirated or exfoliated cellular material. Essentially CBs comprise aggregates of cells but they may add a certain amount of architecture to cytological material making it tempting to use them exclusively without bothering about cytomorphology. Evidence of this temptation is anecdotal, based on personal communication rather than published literature; it may reflect the shortage of pathologists in the UK with an interest in cytology. Jain et al. point out that CBs made from different cell suspensions (saline, methanol, ethanol or formalin) can be prepared from any type of cytological material (needle aspirates, brushings, body fluids, liquid-based preparations or cells scraped from air-dried or alcohol-fixed slides). The method of fixation has some effect on ICC results, as shown in two articles in this issue that report slightly different results with the automated rapid cell block system Cellient, but on the whole CBs can be used very much like histological sections and may be, and frequently are, used for molecular analysis as well.
Systemic and pulmonary diseases that affect the pleura are usually characterised by accumulation ... more Systemic and pulmonary diseases that affect the pleura are usually characterised by accumulation of fluid in the pleural cavity or by fibrous healing of damaged mesothelium. Some of the reactive changes THE The mesothelial cells form a complete layer of cells 176
Summary This article provides an illustrated personal view of the British Society for Clinical Cy... more Summary This article provides an illustrated personal view of the British Society for Clinical Cytology's (BSCC) proposal to modify their terminology for reporting cervical cytology. The BSCC did not propose any major changes but moved closer to the two-tier Bethesda system for reporting pre-cancerous changes as high-grade and low-grade. Certain principles of reporting cytology that were intended in the original BSCC terminology are reinforced and difficult areas of borderline nuclear change are clarified. Revisiting the old terminology has drawn attention to errors and omissions in existing descriptions of dyskaryosis; this term is still used although its definition has been refined. This article will describe and illustrate different manifestations of dyskaryosis, with emphasis on its recognition as such, and its distinction from a wide variety of reactive changes. The illustrations draw widely on one of the author's (LT's) extensive experience with both types of liquid-based cytology preparations, which will now be the predominant methods of cell preparation in the UK.
To audit the use of the ThinPrep Imaging System (TIS) for internal quality control (IQC) in the p... more To audit the use of the ThinPrep Imaging System (TIS) for internal quality control (IQC) in the place of rapid review (RR), and to compare its performance with routine primary screening. During 9 months, 16 462 ThinPrep slides were processed by TIS. Slides were initially reviewed using the TIS review scope, as recommended by the manufacturer: 22 fields of view were observed and, if considered abnormal, a full microscopic review was conducted using the review scope. Different biomedical scientists (BMSs), working on each procedure in rotation, performed batches of TIS-assisted quality control and routine primary screening independently on unmarked slides. Any slides with abnormalities detected by either method were referred to a consultant pathologist or advanced BMS practitioner for a final report. TIS results were compared with both previous records of RR and routine primary screening carried out on the same slides. We used the UK terminology in which &amp;amp;amp;amp;#39;dyskaryosis&amp;amp;amp;amp;#39; is equivalent to squamous intraepithelial lesion (SIL) and borderline to atypical (including squamous and glandular cells). TIS preview detected significantly more high-grade dyskaryosis compared with RR during the previous 4 years: 2.0-4.2 compared with 0.1-1.8 detected per 1000 slides (P = 0.0001). TIS and routine screening were equivalent in sensitivity and specificity for the final cytology result, but BMSs were significantly more likely to classify slides as dyskaryotic rather than borderline when using TIS compared with routine screening. Referrals for potentially high-grade abnormalities detected by TIS-assisted IQC alone found 28 biopsies of at least cervical intraepithelial neoplasia grade 2 (CIN2+), whereas 15 CIN2+ biopsies were found on routine screening but missed using TIS. There was no significant change in the rates of inadequate tests, high- or low-grade cytological abnormalities, or positive predictive value for CIN2+ when TIS was in use. Screening with TIS was more sensitive than RR for IQC, providing a rescreening method equivalent to routine primary screening in overall accuracy.
Introduction The aims of this study were (i) to assess the use of Hybrid‐capture II (HCII) along... more Introduction The aims of this study were (i) to assess the use of Hybrid‐capture II (HCII) alongside conventional cytology for triage of mildly abnormal smears and (ii) to establish the local prevalence of high‐risk human papillomavirus (HRHPV).Study design In an on‐going study, 669 women aged 20–50 were recruited into (i) a study group, with current abnormal cytology or a history of previous abnormal cytology and (ii) an anonymous control group with current negative cytology and no history of abnormal smears. HCII positive was used as a surrogate for mild dyskaryosis in women with negative smears in the study group.Results There was strong correlation between positive HCII tests with degree of cytological abnormality. HCII was positive in 13 of 13 (100%) of women with at least moderate dyskaryosis, 27 of 34 (79%) with mild dyskaryosis, 18 of 36 (50%) with borderline abnormalities, 36 of 250 (14%) of negative smears. In the control group, 50 of 308 (16%) of negative smears were p...
Are significant numbers of abnormal cells lost on the discarded ThinPrepÒ broom when used for cer... more Are significant numbers of abnormal cells lost on the discarded ThinPrepÒ broom when used for cervical cytology? Background: In view of a study with SurePathÒ showing that cells were lost on the broom if it was discarded, we decided to investigate whether cells were lost on the ThinPrepÒ (TP) broom, which is discarded according to the manufacturerÕs protocol. Aim: To determine whether significant amounts of cellular material are lost on the discarded TP broom, and whether the loss is operator dependent. Methods: Three hundred and six women attending the GuyÕs Hospital Colposcopy Unit gave their consent for TP liquid-based cytology samples to be taken and the broom immersed in a second vial instead of being discarded. The cellularity of the first and second vials was compared by counting cells in 10 •40 high-power fields (HPFs). The significance of cell loss was ascertained by correlating the likelihood of abnormal cells and transformation zone (TZ) material being present with the degree of cellularity of the two vials. Results: More than 10 cells per HPF were seen in 3.2%, 19.4% and 35.8% of slides from the second vial taken by three experienced colposcopists, which was significantly different between them (P < 0.001); cellularity of the first vial was not significantly different between colposcopists but the one with highest cellularity in the first vial discarded most in the second. Abnormal cells were more likely to be seen in slides with more than 10 cells per HPF (P < 0.001) and with evidence of TZ sampling (P < 0.001), but there was no preferential loss of TZ material in the second vial. Of 126 slides with abnormal cells on the slides from the second vial, 113 (89.7%) were also present on the significantly more cellular first vial (P < 0.001). Conclusion: Abnormal cells were potentially lost on the broom, but were usually represented in the first vial. The likelihood of abnormal cells being discarded was operator dependent in this small study, but this did not affect the quality of the initial preparation. The likelihood of abnormal cells being seen on TP slides was dependent on their cellularity, which provided our laboratory with a criterion for the assessment of sample adequacy.
Opinions about cervical screening in the UK tend to follow one of two negative lines of thought. ... more Opinions about cervical screening in the UK tend to follow one of two negative lines of thought. The first is that cervical cancer is a rare disease, and too much time and effort are spent on screening. The second is that it has been relatively ineffective, since incidence of invasive carcinoma did not fall until the NHS Cervical Screening Programme (NHSCSP) was introduced in 1988, although it fell by 40% since then. This paper presents publicly available data to demonstrate that neither of these views is true. Registrations of invasive carcinoma of the uterine cervix and carcinoma in situ in England and Wales between 1971 and 1996 show that a substantially increased risk of disease in women born since 1940 has been reversed, almost certainly by greatly improved screening. Cervical carcinoma is now a rare disease because most cases are prevented before they become invasive, mostly by screening young women, aged 20–40, before the decade of life when symptomatic cervical carcinoma mos...
In a 12-year study of the population of Southampton and South-west Hampshire (SSWH), there was no... more In a 12-year study of the population of Southampton and South-west Hampshire (SSWH), there was no rise or fall in the incidence of adenocarcinoma of the uterine cervix, although the incidence of squamous cell carcinoma fell from 14 to 7.2 per 100000 women years and the overall fall in age-adjusted incidence of cervical carcinoma was commensurate with that of England and Wales. The majority (59%) of adenocarcinomas were seen in women aged less than 50, supporting the concept of a higher risk in young women. Screen-detected carcinomas accounted for 50% of adenocarcinomas and 41% of squamous cell carcinomas in women aged 20-64 (the difference was not significant). There were more screen-detected adenocarcinomas of less than 3 mm depth of invasion and 7 mm lateral extension during the third period of the study (1991-1993). The results are consistent with reports of an increased risk of cervical cancer in women born since 1940, and lesser effectiveness of screening in preventing adenocarcinoma compared with squamous cell carcinoma. High prevalence of early screen-detected carcinomas may have been a factor in recent reports of increased incidence of adenocarcinoma.
In this issue of Cytopathology we publish an extensively referenced review article by Austin and ... more In this issue of Cytopathology we publish an extensively referenced review article by Austin and Zhao describing types of cervical cancer that may not be prevented by screening. The authors describe four such types, frequently seen in medicolegal practice, which they categorize collectively as Type 2 cancers: (i) rapidly progressive carcinomas, (ii) carcinomas arising in younger women (in their 20s and 30s), (iii) carcinomas with glandular differentiation and, perhaps more surprisingly, (iv) carcinomas arising in older (postmenopausal) women. Individually these types of carcinoma are rare, but they have become relatively more frequent as regular screening has prevented the majority of cervical cancers in the populations at risk. Also in this issue of Cytopathology, Castanon et al. publish the results of a multicentre cervical cancer audit, with cytology and histology slide review, in the National Health Service Cervical Screening Programme (NHSCSP) and Repše-Fokter et al. report a similar audit of a relatively new but demonstrably successfully organized screening programme in Slovenia. How should the inevitability of false-negative tests be reconciled with public and professional expectations of cancer prevention, while simultaneously avoiding unnecessary investigation and the treatment of young women of childbearing age? False negatives may occur at any stage of the screening process from collecting the sample to colposcopy, and in any type of test. Slides look different in retrospect when the outcome of cancer is known – as recognized by the authors of both cancer audits. Even biopsies may look different in retrospect. Castanon et al. found that of biopsies reported before the eventual diagnosis of cancer as negative, cervical glandular intraepithelial neoplasia (CGIN) or cervical intraepithelial neoplasia (CIN) grade 3, 1%, 15% and 12% respectively were upgraded to cancer on review. In the same audit, 23% of cytology slides reported as negative during the 10 years before diagnosis of cancer were upgraded to high-grade dyskaryosis as were more than half of those originally reported as low grade. Repše-Fokter et al. upgraded 17 out of 33 smears that had been reported as negative, low grade or inadequate within the previous screening round in 42% of all women with cancer. It can be difficult to explain to noncytologists that small, scarce, pale dyskaryotic cells may occasionally be missed and that a single cytology sample may not be representative of an abnormality. Such cases are quite likely to result in litigation because, according to Austin and Zhao, they are disproportionately seen in interval cancers in previously screened women. Cancer audits by their nature review screening histories and slides in women who subsequently develop cancer but Farnsworth, discussing quality control of a highly successful screening programme in Australia, reminds us that women with high-grade CIN have often had previous negative tests. Of women with high-grade lesions on histology, 22% had negative cytology and 13% had negative human papillomavirus (HPV) tests within the previous 30 months. A previous negative test does not negate the value of detecting high-grade CIN on a subsequent test. In well-screened populations, increasing percentages of cancers are in previously screened women, screen-detected and in younger age groups. Incidence of invasive cervical cancer in England has been highest in women aged 30–34 since 2004, but is also increasing in those aged 25–29 and 35–39: by 2009 45% of all cervical cancers were in women in their 20s and 30s (calculated from Office for National Statistics registrations). As Marshall and Zhao point out, cancers in younger women can be difficult to prevent. In an audit carried out at Guy s & St Thomas , two-thirds of women aged 20–34 with cancer had been screened during the previous 5 years, and twothirds in that age group had screen-detected 1A or 1B1 cancers (83.3% of women aged 20–29). RepšeFokter et al. observed that cancers in previously screened women were often diagnosed at an early stage after recent high-grade cytological abnormalities. Just like high-grade CIN, early cancers may not be found on the first test; but that does not negate the clinical value of detecting them on a subsequent test. Aggressive cancers without extensive CIN3 and adenocarcinomas may explain some genuine false negatives that remain negative on review. False negatives as a consequence of abnormalities missed on cytology are an important focus for quality control
Anshu, A. Herbert, B. Cochand‐Priollet, P. Cross, M. Desai, R. Dina, J. Duskova, A. Evered, A. Fa... more Anshu, A. Herbert, B. Cochand‐Priollet, P. Cross, M. Desai, R. Dina, J. Duskova, A. Evered, A. Farnsworth, W. Gray, S. S. Gupta, K. Kapila, I. Kardum‐Skelin, V. Kloboves‐Prevodnik, T. K. Kobayashi, H. Koutselini, W. Olszewski, B. Onal, M. B. Pitman, Ž. Marinšek, T. Sauer, U. Schenck, F. Schmitt, I. Shabalova, J. H. F. Smith, E. Tani, L. Vass, P. Vielh and H. Wiener Survey of medical training in cytopathology carried out by the journal CytopathologyThis report of the Editorial Advisory Board of Cytopathology gives the results of a survey of medical practitioners in cytopathology, which aimed to find out their views on the current situation in undergraduate and postgraduate training in their institutions and countries. The results show that training in cytopathology and histopathology are largely carried out at postgraduate level and tend to be organized nationally rather than locally. Histopathology was regarded as essential for training in cytopathology by 89.5% of respondents and w...
BJOG: An International Journal of Obstetrics & Gynaecology, 2009
To assess the clinical significance of screen-detected cancer compared with symptomatic cervical ... more To assess the clinical significance of screen-detected cancer compared with symptomatic cervical cancer during the introduction of organized screening. Screen-detected and symptomatic cancers were analysed according to International Federation of Obstetrics and Gynecology stage and histological type of cancer and age of women during four 3-year periods. Southampton and South West Hampshire (SSWH). Women resident in SSWH registered with invasive cervical carcinoma between 1985 and 1996. Screen-detected and symptomatic cancers were defined on the basis of clinical information obtained at the time of diagnosis and recorded together with date of diagnosis, age group, histology and cytology results. Data were held for analysis on an anonymous spreadsheet. Incidence of screen-detected and symptomatic cancers per 100 000 women; association between route to diagnosis, age group, stage of cancer and screening history during four 3-year periods. Of 382 cancers, 256 were symptomatic, 78 screen-detected fully invasive and 48 screen-detected microinvasive. Incidence of symptomatic cancers fell from 13.0 to 6.4 per 100 000 total female population (P = 0.0005), and there was a trend towards screen-detected cancers as a proportion of all cancers (P = 0.002). By the latest period of the study (1994-96), the likelihood of cancers being screen-detected was strongly associated with younger age groups (P = 0.001). Screen-detected fully invasive cancers were significantly less likely (P = 0.001) to be diagnosed at stage II or above (16.6%) compared with symptomatic cancers (63.3%). Women with screen-detected microinvasive cancers were significantly more likely (P &amp;amp;lt; 0.001) to have been screened within 5 years (83.3%) than screen-detected fully invasive cancers (60.2%) or symptomatic cancers (33.6%). Screen-detected cancers were more likely to be diagnosed at an earlier stage, in younger women and in women who had previously been screened and became relatively more frequent as symptomatic cancers declined.
sYNoPsis Fixation of lungs at necropsy by inflation with formaldehyde vapour was used in a combin... more sYNoPsis Fixation of lungs at necropsy by inflation with formaldehyde vapour was used in a combined radiological and pathological study of pulmonary oedema. Pulmonary oedema was found in 79 % of lungs examined. The earliest phases affect the interstitial tissue with oedematous connective tissue planes and distension of pulmonary lymphatics. These changes may be associated with reduction in the compliance of the lung. Alveolar filling is a late stage in the accumulation of oedema fluid in the lungs.
To establish a histological standard against which surgical biopsy material could be compared, th... more To establish a histological standard against which surgical biopsy material could be compared, the degree of mesothelial proliferation was studied in 100 unselected necropsies. A minor degree of mesothelial hyperplasia was identified in 10 cases, usually close to areas of fibrous adhesions. Pleural plaques were present in 33 patients but there was no evidence of associated mesothelial proliferation. No mesothelial changes were noted in patients with empyema or pleural metastases. These findings indicate that the degree of mesothelial hyperplasia in common disorders of the pleura is relatively slight. Significant mesothelial proliferation in needle biopsies should therefore be viewed with considerable suspicion and, where clinically appropriate, be followed by further investigation.
Nine primary malignant lymphomas of the lung are described. Seven were localized lesions, and two... more Nine primary malignant lymphomas of the lung are described. Seven were localized lesions, and two were diffuse bilateral infiltrations. Histopathologic examination of these lesions suggests that they represent examples of the same entity and that it is a malignant lymphoma rather than a reactive infiltration or &quot;pseudolymphoma.&quot; Histologic evidence of lymph node involvement is unusual, even in the presence of mediastinal or pleural infiltration. Immunohistochemical studies demonstrated a monotypic B-cell population in cases in which suitable tumor tissue was available for study (four of nine). Of the other five cases, two had a population of monotypic B lymphocytes in the peripheral blood, and in one of these and in one additional case gastric lymphomas subsequently developed. It is suggested that these lymphomas arise from bronchus-associated lymphoid tissue, which would explain both their histologic features and their tendency to remain localized to the lung for long periods.
Cytopathology : official journal of the British Society for Clinical Cytology, 2014
Jain and co-authors at the All India Institute of Medical Sciences (AIIMS), in the lead article i... more Jain and co-authors at the All India Institute of Medical Sciences (AIIMS), in the lead article in this issue of Cytopathology, explain the enormous advantages of cell blocks (CBs) as an adjunct to cytology. The authors also mention their limitations and the differences between methods; and they make the important point that CBs are ‘not a substitute but complementary to conventional cytology techniques’. Nevertheless, in practice CBs are sometimes used instead of cytology in centres where pathologists’ have less confidence in cytology. Seven years as editor of Cytopathology has led me, on looking back over publications in this journal, to reflect on why we need cytological preparations, why it has been said that ‘most pathologists are not interested in cytology’, and why training in cytopathology in the UK and elsewhere in Europe remains a problem. Medical and non-medical cytologists work closely together and depend on each others’ skill: principles for an extended role of cytotechnologists (CTs) discussed in the October issue of Cytopathology are also relevant to pathologists. These surveys and discussions include examples of good practice in other countries, such as the USA and Australia, to which this editorial refers. Cell blocks provide a method for immunocytochemistry (ICC) that has revolutionized cytopathology by making it possible to apply panels of antibodies to multiple sequential sections of aspirated or exfoliated cellular material. Essentially CBs comprise aggregates of cells but they may add a certain amount of architecture to cytological material making it tempting to use them exclusively without bothering about cytomorphology. Evidence of this temptation is anecdotal, based on personal communication rather than published literature; it may reflect the shortage of pathologists in the UK with an interest in cytology. Jain et al. point out that CBs made from different cell suspensions (saline, methanol, ethanol or formalin) can be prepared from any type of cytological material (needle aspirates, brushings, body fluids, liquid-based preparations or cells scraped from air-dried or alcohol-fixed slides). The method of fixation has some effect on ICC results, as shown in two articles in this issue that report slightly different results with the automated rapid cell block system Cellient, but on the whole CBs can be used very much like histological sections and may be, and frequently are, used for molecular analysis as well.
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