Is colposcopy always necessary with atypical glandular cells of undetermined significance on Papanicolaou smears?

The objective of this study was to review a 5-year experience with atypical glandular cells of undetermined significance (AGUS) on Papanicolaou smear and to use the information to devise a triage method for patients presenting with this abnormality. Our Papanicolaou smear database was used to identify patients who were found to have AGUS results between January 1, 1994 and December 31, 1998. The medical records of these patients were reviewed for the results of follow-up studies, including repeat Papanicolaou smear, endocervical curettage, colposcopic directed biopsies, and endometrial biopsy. During the study period, 27,859 Papanicolaou smears were performed, with 306 (1.1%) being reported as AGUS; 18 patients had two AGUS smears. An additional 24 patients did not meet study criteria. The study group then consisted of 264 patients, of whom 244 (92.4%) reported for follow-up. There were 167 (63.3%) with atypical endocervical cells of undetermined significance (AECUS), 14 (5.3%) with atypical endometrial cells of undetermined significance, and 83 (31.4%) with AECUS plus a squamous cell abnormality. The overall prevalence of a high-grade squamous intraepithelial lesion (HSIL) was 11.8%. The prevalence of HSIL in the AECUS plus squamous cell abnormality group was 25.4%. None of the atypical endometrial cell group had HSIL. In the AECUS, favor dysplasia category, 29.4% had HSIL, whereas in the AECUS, favor reactive process or in unqualified, 2.3% had HSIL. Eighty-one patients underwent endometrial biopsy: three (3.7%) were found to have endometrial adenocarcinoma, and two (2.5%) had complex atypical endometrial hyperplasia. The prevalence of HSIL in patients with AECUS, favor reactive process or AECUS, unqualified Papanicolaou smears is low. Colposcopy is not necessary as an initial triage process for this category of patients. A significant percentage of patients with AECUS, favor dysplasia or AECUS with a squamous epithelial abnormality Papanicolaou smears have HSIL; this subset of patients should be investigated with colposcopy.

Cervicography combined with repeat Papanicolaou test as triage for low-grade cytologic abnormalities.

OBJECTIVE: To determine the efficacy of combined repeat Papanicolaou test and cervicography for identification of high-grade squamous lesions among patients who previously have had atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesion (LSIL) diagnosed by the Bethesda System. METHODS: All patients who presented to a charity hospital gynecology clinic between July 1, 1994, and December 31, 1995, with a Papanicolaou test result of ASCUS or LSIL underwent repeat Papanicolaou test, cervicography, colposcopy with colposcopic-directed biopsy when appropriate, and an endocervical curettage. Pregnant patients and those who had undergone hysterectomy were excluded. The mean and median time from abnormal Papanicolaou test to clinical investigation was 61 and 58 days, respectively (range 6-162 days). RESULTS: One hundred eighty-seven of the patients had an initial ASCUS Papanicolaou test. Of these 187, 24 (13%) were found to have cervical intraepithelial neoplasia (CIN) grades II-III. The second Papanicolaou test would have resulted in the detection of 11 of 24 lesions (sensitivity 46%), whereas the cervigram would have detected 22 of 24 (sensitivity 92%). The combined Papanicolaou test and cervigram sensitivity for ASCUS was 91%. One hundred forty-one of the patients had an initial LSIL Papanicolaou test. Of these 141, 37 (26%) patients were found to have CIN II-III. The repeat Papanicolaou test would have detected 29 of 37 lesions (sensitivity 78%), whereas the cervigram would have detected 33 of 37 (sensitivity 89%). The combined Papanicolaou test and cervigram sensitivity for LSIL was 97%. CONCLUSION: Cervicography is a helpful adjunctive technique for detection of CIN II-III lesions in patients with previous ASCUS or LSIL Papanicolaou tests.

Obstetric and gynecologic malpractice in Louisiana: incidence and impact.

A survey of Louisiana obstetricians and gynecologists on the subject of professional liability was conducted in July 1988 by the Louisiana Section of the American College of Obstetricians and Gynecologists. Survey results disclose that the incidence of obstetric and gynecologic malpractice claims approximated the national incidence of such claims. The economic impact of these claims is less than that experienced on a nationwide basis. However, 85% of survey respondents indicated that they had made changes in their practice as a result of the risk of malpractice litigation. Many of these changes have adverse implications for the patient. If the present trends continue, it is likely that Louisiana women will find obstetric services more expensive and much less available.