RESUMEN
Competency assessment is an ongoing, continuous process of monitoring individuals' abilities to perform their specific job functions. A variety of methods are useful in monitoring cytology competency, including rescreening studies, descriptive monitors (abnormality rates), discrepancy rates, workload patterns, competency-based educational programs and programs using unknown slide challenges. The goal of proficiency testing (PT) is to ascertain and assess the ability of individuals beyond the particular items or challenges presented. However, cytology PT faces many challenges for implementation as it cannot duplicate normal working conditions, and there is often no gold standard to define the truth. PT is just one measure of performance and should be considered in conjunction with other quality assessment monitors. There is no consensus on the value or validity of a large-scale regulatory PT program. Any regulatory PT program should be field tested prior to implementation, and the grading system should be scientifically defensible. Scoring of performance on PT should occur in a timely fashion, and there should be an opportunity for educational feedback. The ultimate aim of both competency assessment and PT is to positively affect laboratory procedures and improve the cervical cancer screening process.
Asunto(s)
Biología Celular/normas , Laboratorios/normas , Competencia Profesional , Frotis Vaginal/normas , Femenino , Humanos , Tamizaje Masivo , Control de Calidad , Neoplasias del Cuello Uterino/patología , Carga de TrabajoRESUMEN
To obtain an adequate cervical smear for making a correct cytologic diagnosis, smear taking, laboratory handling and interpretation must be optimal. Many people are involved, and only by a combined effort of all links can this target be seriously approached: the smear takers will have to be open minded about technical improvements and read the morphologic descriptions cautiously; in the laboratory, cytotechnicians and physicians will have to challenge themselves and each other. It is mandatory to discard specimens that do not meet general standards of adequacy. At present a host of new techniques are being implemented. It is not feasible for all laboratories to be engaged in testing these new methods, but we are all requested to follow the development the best we can and switch to new ways when justified. Our working conditions are very different; therefore, it is our professional responsibility and plight to respond at the right time. So far the conclusion is that the conventional Pap smear is the international standard of care for the diagnosis of cervical cancer precursers in cancer screening programs. Certainly, this may change within a very short time. Liquid-based techniques, and in particular HPV technologies, are just around the corner.
Asunto(s)
Biología Celular/normas , Laboratorios/normas , Prueba de Papanicolaou , Manejo de Especímenes , Neoplasias del Cuello Uterino/patología , Frotis Vaginal/normas , Femenino , Humanos , Tamizaje Masivo , Control de CalidadRESUMEN
Cervical cancer continues to be a major cause of death in women worldwide. The major problem facing most women is the unavailability of screening Pap tests in poor and underdeveloped countries. While rates of cancer deaths have decreased 60-80% in developed countries since the Pap test became available, the accuracy of Paps was challenged recently. In order to instill public confidence and promote optimal patient care, measures to improve the quality of the entire screening process should be undertaken. Continuous quality improvement processes are more appropriate than traditional quality assurance monitors. Although no standards can be defined that are applicable to all laboratory settings and nations, this document provides current views on universal quality procedures and risk reduction. Procedure/policy manuals, workload assessment, hierarchic/peer review, discrepancy analysis, rescreening studies and cytohistologic correlation are examples of universally applicable quality tools. The variability in practices in different parts of the world is also discussed.
Asunto(s)
Tamizaje Masivo/normas , Guías de Práctica Clínica como Asunto , Control de Calidad , Neoplasias del Cuello Uterino/prevención & control , Femenino , Humanos , Frotis Vaginal/normasAsunto(s)
Neoplasias del Cuello Uterino/diagnóstico , Frotis Vaginal/normas , Carcinoma de Células Escamosas/diagnóstico , Carcinoma de Células Escamosas/patología , Análisis Costo-Beneficio , Femenino , Humanos , Programas Controlados de Atención en Salud , Pennsylvania , Reproducibilidad de los Resultados , Riesgo , Sensibilidad y Especificidad , Neoplasias del Cuello Uterino/economía , Frotis Vaginal/economía , Frotis Vaginal/métodosRESUMEN
ISSUES: The conference participants addressed the following issues: (1) reporting of equivocal diagnoses, (2) strategies to minimize the use of such diagnoses, (3) morphologic criteria, and (4) management of women with equivocal diagnoses. CONSENSUS POSITION: Equivocal diagnoses should be minimized, to the extent possible, by emphasizing cytologist education and training, improved specimen collection and quality assurance monitoring of individual and laboratory diagnosis rates. Cases fulfilling criteria for other diagnostic entities should not be included in the equivocal category. Regardless of the term utilized, an equivocal diagnosis should be qualified in some manner to indicate that the diagnosis defines a patient at increased risk of a lesion, particularly for those cases which raise concern about a possible high grade lesion. Qualification of an equivocal diagnosis can also be accomplished by appending laboratory statistics of the likelihood of various clinical outcomes or recommendations for patient follow-up. In contrast to favoring a reactive process versus squamous intraepithelial lesion (SIL), a more rationale approach to qualification of atypical squamous cells of undetermined significance may be to separate cases equivocal for low grade SIL from those suspicious for high grade SIL. With regard to glandular lesions, the conference participants expressed unanimous support for the separation of adenocarcinoma in situ (AIS) from atypical endocervical cells of undetermined significance when sufficient criteria are present. However, the diagnosis of a precursor lesion to AIS, endocervical glandular dysplasia, was controversial. The majority of conference participants discourage the use of such terms as mild glandular dysplasia and low grade glandular dysplasia for cytologic diagnoses. ONGOING ISSUES: Conference participants agreed that a term reflecting diagnostic uncertainty is necessary to communicate findings that are equivocal. However, participants could not agree on the wording of such a term. Opinions differed as to: (1) use of atypical, abnormal or morphologic changes to describe cell changes, (2) whether the diagnosis should indicate a squamous or glandular origin of the cells in question when this determination can be made, and (3) the value of defining morphologic criteria for such a diagnosis. The debate over terminology, as well as morphologic criteria, is ongoing, and the readership is invited to communicate opinions to Acta Cytologica. Management of women with equivocal diagnoses varies widely from locale to locale and may differ based on how the equivocal diagnosis is qualified. Findings insufficient for the diagnosis of a high grade lesion may warrant more aggressive follow-up than cases equivocal for a low grade lesion. Where sensitivity of detection of lesions is of paramount importance, follow-up will generally consist of more frequent cytology screening or colposcopy and biopsy. However, in some countries it is considered unethical to have a high percentage of false positive diagnoses, which result in overtreatment and an unnecessary burden for women participating in cervical screening. Future studies may provide a morphologic, or perhaps molecular, basis for distinguishing true precursors of neoplasia from minor lesions of no significant clinical import; this would allow a more coherent and rational approach to diagnosis and management of women with equivocal cytologic findings.
Asunto(s)
Cuello del Útero/patología , Células Epiteliales/patología , Displasia del Cuello del Útero/diagnóstico , Neoplasias del Cuello Uterino/diagnóstico , Frotis Vaginal/normas , Adenocarcinoma/diagnóstico , Adenocarcinoma/patología , Atrofia , Núcleo Celular/ultraestructura , Citoplasma/ultraestructura , Diagnóstico Diferencial , Glándulas Exocrinas/patología , Femenino , Humanos , Metaplasia , Reproducibilidad de los Resultados , Terminología como Asunto , Displasia del Cuello del Útero/patología , Displasia del Cuello del Útero/terapia , Neoplasias del Cuello Uterino/patología , Neoplasias del Cuello Uterino/terapiaRESUMEN
ISSUES: Differences in type, structure, quality of health care systems and availability of resources influence reporting systems. In most countries, individual systems have a long history of usage that might preclude adoption of a uniform terminology worldwide. CONSENSUS POSITION: It is desirable but unrealistic at this time to aim for a unified terminology worldwide. It should be the stated objective of the International Academy of Cytology to serve as an umbrella organization for various terminologies and enhance mutual understanding and cooperation. Translation tables of equivalent terms have been created to allow increased communication. Consensus has been achieved in defining essential elements required of any terminology system: (1) the report must be text based: numerical Papanicolaou class designations alone are inadequate; (2) an assessment of the adequacy of the sample should be included; and (3) the diagnosis must address the primary purpose of cervical cytology: to indicate the presence or absence of epithelial abnormalities. Incorporating additional elements within a terminology system may be more or less appropriate, depending on the setting in which the system is used. ONGOING ISSUES: Despite the cited problems in adopting a uniform terminology worldwide, a single system would have many advantages in terms of communication and research and may be a long-term goal worth pursuing. Countries are invited to present their individual national terminology systems and participate in an ongoing dialogue, critically evaluating the advantages and disadvantages of all systems.
Asunto(s)
Técnicas Citológicas , Terminología como Asunto , Enfermedades del Cuello del Útero/clasificación , Neoplasias del Cuello Uterino/clasificación , Cuello del Útero/patología , Técnicas Citológicas/normas , Epitelio/patología , Femenino , Humanos , Prueba de Papanicolaou , Papillomaviridae , Infecciones por Papillomavirus/clasificación , Infecciones por Papillomavirus/patología , Sociedades Científicas , Infecciones Tumorales por Virus/clasificación , Infecciones Tumorales por Virus/patología , Enfermedades del Cuello del Útero/patología , Neoplasias del Cuello Uterino/patología , Cervicitis Uterina/clasificación , Cervicitis Uterina/patología , Cervicitis Uterina/virología , Frotis Vaginal , Displasia del Cuello del Útero/clasificación , Displasia del Cuello del Útero/patologíaRESUMEN
ISSUES: General definitions of quality assurance and quality control (QA/C) have existed in many forms for decades, and a new discipline guides their application to diverse industrial and recently medical processes without much fanfare. However, in the field of cervical cytology screening, the range of QA/C options has recently broadened and become controversial. With the advent of new systems of terminology, larger-scale laboratories and new technologies--plus strong governmental and legal pressures in some nations--the range of extremely difficult and sometimes expensive QA/C choices our community faces is greater than ever. CONSENSUS POSITION: At our conference, the basic definitions of QA/C posed little difficulty. Presentation of the range of methods in use today and of those based on new technologies where use is proposed or has just begun also was achieved with little or no dispute. However, there was lack of consensus on exactly how QA/C methods are to be assessed. Indeed, there was little consistency in the use of different outcome measures with which we can judge success or failure of specific QA/C options. In addition, the tension between pressure to adopt sometimes uncertain or expensive method enhancements and pressure to maintain affordability and the widest possible access for populations that most need cervical cytology screening is greater than ever. ONGOING ISSUES: More data are required that would enable assessment of QA/C options with the clearest possible understanding of cost/benefits and current or new assumptions of risk. Other task forces, such as medicolegal, cost/benefit and those devoted to new technologies, are our essential partners in meeting the challenges described above.
Asunto(s)
Técnicas Citológicas/normas , Garantía de la Calidad de Atención de Salud , Control de Calidad , Centers for Medicare and Medicaid Services, U.S. , Difusión de Innovaciones , Femenino , Humanos , Evaluación de Resultado en la Atención de Salud , Salud Pública , Garantía de la Calidad de Atención de Salud/métodos , Estados Unidos , Enfermedades del Cuello del Útero/patología , Neoplasias del Cuello Uterino/patología , Neoplasias del Cuello Uterino/prevención & control , Frotis Vaginal/normasRESUMEN
From June 1 through December 3, 1991, 146 women were referred to the Gynecology Outpatient Clinic of Nahariyya Medical Center for uterine bleeding and pathologic conditions. Their ages ranged from < 40 (26 patients) to > or = 60 (18 patients), with 60 (41%) in the 40-49 age group. An Endopap endometrial sampling pilot study was undertaken to find a correlative index between cytologic, histologic and hysteroscopic sampling methods as well as to investigate the possibility that Endopap sampling could avoid excessive use of nontherapeutic dilation and curettage. In 118 patients for whom concomitant cytologic and histologic specimens were available there was no statistically significant difference between the number of correct cytologic and histologic diagnoses of intrauterine pathology. Cytodiagnostic accuracy of the Endopap samples was expressed in terms of sensitivity (68.2%), specificity (80.7%), predictive value of a malignant test result (100%) and predictive value (PV) of an abnormal (hyperplasia) test result (73.2%). The lower values for sensitivity, specificity and PV in this study as compared with those in the literature were probably due to three attenuating factors: the relatively small number of patients (146), the fact that the cytodiagnostic accuracy for hyperplasia and precursor lesions of endometrial carcinoma is significantly lower than for histologic diagnosis, and the presence of 15 (10.3%) inadequate cytologic specimens. The results did tend to concur with the range of reported results. It is recommended that Endopap sampling be employed in cases of medically and anatomically contraindicated dilation and curettage--e.g., cervical canal stenosis and intrauterine adhesions (Asherman's syndrome)--in monitoring perimenopausal and postmenopausal patients on estrogen replacement therapy and in obese women, diabetics and hypertensives at risk of developing endometrial hyperplasia. The study also showed that the combined hysteroscopic and Endopap techniques could result in increased rates of sensitivity and specificity.
Asunto(s)
Neoplasias Endometriales/patología , Endometrio/patología , Histeroscopía , Lesiones Precancerosas/patología , Adulto , Factores de Edad , Endometrio/citología , Femenino , Humanos , Hiperplasia , Persona de Mediana Edad , Proyectos Piloto , PosmenopausiaRESUMEN
Involvement of the gastrointestinal tract in systemic lupus erythematosus is well documented but small intestinal malabsorption is a rare event. We report a 27 year old woman with systemic lupus erythematosus who had malabsorption and coeliac-like changes on intestinal biopsy. This is the eighth reported case of this association the significance of which is discussed.
Asunto(s)
Enfermedad Celíaca/complicaciones , Lupus Eritematoso Sistémico/complicaciones , Adulto , Enfermedad Celíaca/patología , Femenino , Humanos , Yeyuno/patologíaRESUMEN
This case report depicts an interesting association of well-differentiated adenocarcinoma of the endometrium with benign squamous metaplastic foci confined to the fundus uteri, superficially invading the myometrium and with concomitant bilateral pelvic lymph node endometriotic adenoacanthomas. Right inguinal lymphadenopathy was detected during the first hospitalization. A lymph node biopsy from the right groin, carried out at Nahariyya, revealed apparent metastatic adenoacanthoma regarded most probably as endometrial in origin. Fractionated curettage later showed a stage Ia G1 adenocarcinoma of the endometrium with benign squamous metaplastic elements (adenoacanthoma). At Rambam Hospital, Haifa, left groin node enlargement was noted as well. The Gynecologic Oncology Unit confirmed the previous histologic findings. At exploratory laparotomy total abdominal hysterectomy and bilateral salpingo-oophorectomy, paraaortic, and bilateral pelvic lymph node sampling as well as appendectomy were performed. Bilateral groin node dissection was then carried out. Out of 37 nodes examined tumor was found in only one node, namely that of the left groin. The paper includes an extensive survey of the literature on the subject of the histopathogenesis of endometriotic foci in pelvic lymph nodes and the discussion is designed to elucidate the diagnostic problem involved in this case report.
Asunto(s)
Adenocarcinoma/patología , Neoplasias Uterinas/patología , Útero/patología , Endometrio/patología , Femenino , Humanos , Conducto Inguinal , Ganglios Linfáticos/patología , Metástasis Linfática , Persona de Mediana EdadRESUMEN
Primary and isolated lymphoma of the head of pancreas with secondary involvement of the lungs and obstructive jaundice, in a 31-year-old postpartum woman, is described. The histological diagnosis was diffuse histiocytic lymphoma. Chemotherapeutic treatment resulted in complete remission of the tumor. During therapy a pseudocyst of the pancreas developed and a gastrocystostomy was performed. This is the second reported case of primary pancreatic lymphoma in the English medical literature.
Asunto(s)
Linfoma de Células B Grandes Difuso/diagnóstico , Neoplasias Pancreáticas/diagnóstico , Adulto , Terapia Combinada , Urgencias Médicas , Femenino , Humanos , Linfoma de Células B Grandes Difuso/patología , Linfoma de Células B Grandes Difuso/terapia , Páncreas/diagnóstico por imagen , Páncreas/patología , Neoplasias Pancreáticas/patología , Neoplasias Pancreáticas/terapia , Seudoquiste Pancreático/diagnóstico por imagen , Seudoquiste Pancreático/patología , Seudoquiste Pancreático/cirugía , Inducción de Remisión , Reoperación , Factores de Tiempo , Tomografía Computarizada por Rayos XRESUMEN
We studied a series of 40 rats at various stages of colorectal carcinoma, as induced by N-methyl-N-nitro-Nitrosoguanidine. Lymphokine containing supernatants were obtained simultaneously from splenic and peripheral lymphocytes, after exposure to rat colon cancer antigen in vitro. The lymphokine was found capable of performing Macrophage Migration Inhibition (MIF) when obtained from rats with: carcinoma through serosa, carcinoma of submucosa, carcinoma of the mucosa and carcinoma in situ. All control rats were free of cancer and were MIF negative. The MIF response in this study was evaluated as a marker of chemically induced colorectal carcinoma in rats in order to better understand the lymphocyte response to tumor progression from atypia to adenocarcinoma of the colon.
Asunto(s)
Adenocarcinoma/metabolismo , Neoplasias del Colon/metabolismo , Linfocinas/biosíntesis , Factores Inhibidores de la Migración de Macrófagos/biosíntesis , Adenocarcinoma/inducido químicamente , Adenocarcinoma/inmunología , Animales , Antígenos de Neoplasias/inmunología , Neoplasias del Colon/inducido químicamente , Neoplasias del Colon/inmunología , Masculino , Metilnitronitrosoguanidina , Ratas , Ratas EndogámicasRESUMEN
A 49-year-old patient presented with urticaria, vomiting, diarrhea and peripheral eosinophilia. A histological diagnosis of eosinophilic gastroenteritis was made. Within 3 weeks of admission a highly papillary adenocarcinoma of the right ovary was diagnosed. The gastrointestinal symptoms and the eosinophilia disappeared after partial resection of the tumor and chemotherapy. A possible relationship between cancer, eosinophilia and eosinophilic gastroenteritis is discussed.