Cervical Cytology and Histology Correlation as an Analytic Quality Assurance Exercise: Experience from an Accredited Cytology Laboratory.

Context: The performance parameters of cervical cytology in any accredited cytology laboratory requires implementation of quality control exercise, which ensures acceptable performance by a laboratory. This study aims to assess the analytical aspect of quality control measures by evaluating the frequency and accuracy of epithelial abnormalities as detected in cervical Pap smears using histopathologic diagnosis as the gold standard. Methods: A retrospective diagnostic test study from 2018 to 2020 was conducted. Out of the total 6000 Pap smears, histopathologic correlation was available in 150 cases in the form of colposcopic-directed biopsy (CDB) and loop electrosurgical excision procedure (LEEP) tissue in 105 cases. The quality control measures analyzed were Atypical Squamous Cell: Squamous Intraepithelial Lesion (ASC: SIL) ratio, cyto-histo correlation, and study parameters like sensitivity, specificity, positive predictive value, and negative predictive value of Pap smears as against CDB and LEEP. Results: 4.5% smears were reported as inadequate, 92.3% as Negative for intraepithelial lesion or malignancy (NILM), followed by epithelial abnormality found in 3.21%. The ASC: SIL ratio was 1.3:1. Concordance rate against CDB was 100% in Squamous cell carcinoma (SCC), 82.35% in high-grade squamous intraepithelial lesion (HSIL), 82% in atypical squamous cells of undetermined significance (ASCUS), 65.6% in low-grade squamous intraepithelial lesion (LSIL), and 50% in Atypical Squamous Cell ,High grade Squamous Intraepithelial Lesion can not be ruled out (ASC-H). Total concordance rate was 84.15%. Sensitivity of Pap smear was 65% for LSIL and 82% for HSIL. Specificity, positive predictive value, and negative predictive value were 63.63%, 90%, and 75%, respectively. Concordance rate was 96% with LEEP. Conclusion: Quality control measures give an insight of performance of any accredited cytology laboratory. This exercise needs to be conducted on a regular basis, so that relevant steps can be taken in case of major discrepancy.

Study of Extramedullary Lymphoblastic Lymphoma (LBL) Diagnosed by Flowcytometric Immunophenotyping (FCI) on Fine Needle Aspirate (FNA) Sample-A Case Series of 18 Cases.

Background: Lymphoblastic lymphoma (LBL) accounts for about 2% of all lymphomas. Recognition of T/B-LBL albeit of their rareness is very important as they present as localized diseases with low tumor burden. They can present both at nodal and extranodal sites. Limitation of diagnosis and classification of lymphoma on fine needle aspirate (FNA) can be minimized by clubbing it with flowcytometric immunophenotyping (FCI) to ensure diagnostic accuracy rapidly. Aim: Study of a series of 18 cases of LBL to assess the utility of FCI on FNA and effusion samples in extramedullary LBL. Methods and Material: FCI was done on FNA and effusion samples from 130 morphologically diagnosed/suspicious cases of lymphoreticular malignancy, followed by peripheral blood and bone marrow (BM) examination. The patients diagnosed to have B/T LBL, based on WHO 2017 classification, were selected for further analyses. Results: FCI of 130 cases showed 91 mature and 18 precursor lymphoid neoplasms. These 18 cases were from lymph nodes (11), pleural fluid (03), and soft tissue masses (04). Peripheral blood and BM of 15/18 cases were normal of which FCI revealed T-LBL (11) and B-LBL (04). Two cases (both T LBL) showed BM involvement (<25%), while one case of B-LBL which was misdiagnosed as mature lymphoma by immunohistochemistry (IHC) evolved as B ALL. Conclusions: Diagnosis of extramedullary B/T-LBL needs comprehensive evaluation of clinical presentation, cytomorphology, and immunophenotyping. Rapid and accurate diagnosis by FCI on FNA and effusion samples allows early therapeutic decisions, thereby avoiding leukemic dissemination.

Body fluids: Comparison of liquid based cytology with conventional cytopreparatory technique.

Introduction: In the diagnosis of malignant tumors, cytological examinations of various body fluids are useful. For the preparation of body fluid, many methods are used till date. The use of liquid-based cytology is new upcoming in the field. Aim: To examine the performance of liquid-based cytology on body cavity fluids as compared to conventional cytopreparatory techniques. Methodology: In the present study, 700 body fluid samples were processed by both liquid- based cytology (BD SurePath™) and conventional cytopreparatory technique (Thick & Thin). The performance of both techniques was compared in terms of "smear quality" and "overall diagnostic test performance." Results: Out of 155 body fluid samples from proven malignancy patients, 32 (20.65%) were reported as Positive for malignancy, 23 (14.84%) as Suspicious of malignancy, and 100 (64.51%) as Negative for malignancy by CS (Thick and Thin). A total of 44 (28.39%) were reported as Positive for malignancy, 12 (7.74%) as Suspicious of malignancy, and 99 (63.87%) as Negative for malignancy by LBC. Conclusion: Liquid-based cytology is advantageous over conventional techniques in cytomorphology of body fluids, but not better in sensitivity and specificity. Also saves cytopathologist's valuable time for screening.

Nuances of the Papanicolaou stain.

The impressive list of achievements of Dr. G. N. Papanicolaou and his tedious journey from normal to abnormal human cell includes the importance of wet fixation of cells and the development of the unique polychromatic Pap stain. The 5-dye Pap stain method evolved through 2 salient phases. The first being the development of wet fixation using alcohol-ether to enhance cellular transparency and the second phase saw the introduction of various cytoplasmic counterstaining methods using orange G and EA (light green, Bismarck brown, eosin) and phosphotungstic acid, facilitating the distinction of cell types. The specific characteristics of the staining method is, the cellular transparency combined with crisp nuclear staining, achieved through tailored cellular fixation and cytoplasmic staining using variable dye and pH combinations. With little modifications if any the Pap stain continues to be applied uniformly globally. However, institutional supply of dyes and chemicals from different companies make minor modifications, that remain consistent, an essential part of the staining protocol. This chapter describes the preparation and principles of various components of the stain that are being currently used in our department.

Cervical Pre-cancers: Biopsy and Immunohistochemistry.

The existence of precursor lesions for invasive cervical cancer has been recognized for more than 50 years. Our understanding of the pathobiology and behavior of cervical cancer precursors has evolved considerably over the past five decades. Furthermore, the terminology used to classify pre-invasive lesions of the cervix has frequently changed. The realization that human papillomavirus (HPV) infections constitute a morphologic continuum has prompted efforts to include them within a single classification system, specifically the squamous intraepithelial lesions (SILs) which have now been embraced by the surgical pathologists. The reduced number of specific pathological categories has made clinical decision-making more straightforward. The generic criteria for SIL have two important histological parameters: Alterations in the density of superficial epithelial cells and superficial squamous atypia. The flat condyloma or cervical intraepithelial neoplasia (CIN) I is generally associated with intermediate and high-risk HPV types as against the low-risk viruses that cause exophytic/papillary growth patterns of condylomas. The diagnosis of low-grade SIL (LSIL) (flat and exophytic condylomas) requires first excluding benign mimics of LSIL and second to confirm the characteristic cytologic atypia. For high-grade SILs (HSILs), the extent and degree of atypia generally exceed the limits of that described in flat or exophytic condylomas (LSILs). Less maturation, abnormal cell differentiation, loss of cell polarity, and increased mitotic index with abnormal mitotic figures occupying increasing thickness of the epithelium define a lesion as CIN II or CIN III. Atypical immature metaplasia associated with inflammation and atrophy is a challenge in cervical biopsy interpretation. Careful attention to the growth pattern of the epithelium, the distribution of the atypia, nuclear spacing, and the degree of anisokaryosis and the presence of enlarged hyperchromatic nuclei help in differentiating a non-neoplastic from a neoplastic process. This chapter describes in depth the diagnostic difficulties in the interpretation of cervical biopsies. It also provides useful criteria in distinguishing benign mimics from true precancerous lesions and the role of biomarkers such as the p16ink4 and Ki-67 in the differential diagnosis of precursor lesions and the reactive and metaplastic epithelium.

The Pap smear in inflammation and repair.

Cytology of the uterine cervix is one of the most widely utilized tests and is best known primarily for the cytologic changes seen in precancerous lesions and invasive cancer of the uterine cervix. The more common inflammatory conditions of cervicitis and vaginitis are close clinical differentials, especially when they give rise to excessive blood-stained vaginal discharge. These infective conditions also result in variation in the appearance of otherwise benign squamous and glandular cells in cervical cytology specimens. A variety of physiologic and pathologic conditions are responsible for the conversion of polymicrobial flora of the vagina to a monomicrobial one. The latter may overgrow the others and result in inflammation of the cervix and the vagina. Chronic irritation of the cervix due to intrauterine devices, chemical irritants, inflammation/infection, endocrine changes, and reparative changes can lead to worrisome parakeratosis, hyperkeratosis, and squamous metaplasia of non-keratinized squamous mucosa of the cervix and the vagina and may mimic HPV-related changes. Although some benign changes are specific for certain infections, for example, Trichomonas infestation, most of the reactive and hyperplastic cell morphology are important to recognize only due to the significant morphologic overlap with neoplastic changes in cytology specimens. Identification of different pathogens specifically may not be relevant from a clinical point of view, but is undoubtedly a cytologists' privilege to inform the clinician! This chapter describes in detail the cytoplasmic and nuclear reactive changes that are found in specific and non-specific inflammatory conditions. In addition, diagnostic pitfalls are emphasized where necessary.

The gray zone squamous lesions: ASC-US / ASC-H.

The unequivocal and easily recognizable entities of LSIL and HSIL pose no diagnostic problems for a trained eye. However, when the defining morphologic features are either qualitatively or quantitatively insufficient, it is then that the borderline category of "Atypical Squamous cells" (ASC) may have to be used. Scant and suboptimal preparations (mainly in conventional smears) are the common causes that hinder confident decision-making. The binary classification of the ASC category has been retained in The Bethesda System 2014. It includes ASC of undetermined significance (ASC-US) when the atypia is seen in mature cells and ASC-cannot rule out high-grade lesion (ASC-H) when borderline changes are seen in less mature, smaller metaplastic cells or smaller basaloid cells. There are many criticisms of the ASC category. The major one is its subjective and inconsistent applications and the low interobserver and intraobserver reproducibility. However, studies have shown that if we eliminate ASC-US, the LSIL rate will increase. If ASC-H is eliminated, the chances of detecting true lesions are reduced. Hence, there are strong reasons to retain the ASC category. The usual problems leading to the categorization of such cells as atypical are hyperchromasia beyond that acceptable as reactive change; abnormal chromatin pattern that is not overt dyskaryosis; minor variations in nuclear shape; and membrane outlines. Qualifying the atypical cells precisely in one of the categories has bearing on the clinical management and follow-up of the patient. Surveillance of women under the ASC-US category is either by repeat smear at 6 months and 1 year or by reflex human papillomaviruses DNA testing. Women with a Pap smear interpretation of ASC-H are directed to undergo immediate colposcopy. This article describes in detail the morphologic features of the ASC category, doubts about the correct interpretation of the chromatin pattern of the cells in question, and the differential diagnosis between normal, reactive, or inflammatory conditions, and LSIL/HSIL.

Pap Smear Collection and Preparation: Key Points.

Cytology is the science of study of cells. It is derived from the Greek word "cytos" which means cells. The cells of the cervicovaginal epithelium are continuously evolving. The mature cells reach the surface and are then exfoliated. Initially, these exfoliated cells were collected from the posterior fornix, which showed cells from endocervix, ectocervix, and the vaginal epithelium. Hence, it was known as the exfoliative vaginal cytology. But now, the cells are taken directly by scraping the ecto and the endocervix. A variety of sampling devices are available in the market. The basic aim is to augment sampling of the complete transformation zone (TZ) as well as the squamocolumnar junction (SCJ) and cause least possible trauma to the cervical and endocervical epithelium during its use. The SCJ is of crucial significance for cervical cancer pathogenesis. Most of the precancerous changes take place within the TZ and at the SCJ. Hence, the collection of cells from this area is of utmost importance. The reliability of cervical cytology for the detection of precancerous lesions also strongly depends on immediate wet fixation of the smear. Therefore, the gynecologists or the paramedics who perform the conventional Pap smears must not only be trained in the art of cell collection and smearing of the material onto the glass slides but also learn immediate wet fixation of the cervical cells. Liquid-based preparations have made all these steps relatively easy for them as the design of the Cervex brush is such that it mostly ensures the sampling of the complete TZ and the SCJ. Pre-fixation of cells occurs in the vial containing a weak fixative and the transfer of cells onto the glass slide is standardized by the automated stations designed for this purpose. This chapter gives an in depth description of the prerequisites and precautions while collecting and preparing a Pap smear with different devices, especially for settings where conventional smears are still the norm. Instructions for women undergoing Pap smear and the medical personnel who conduct this test are also highlighted.

Nonneoplastic Cervical Cytology.

Diagnostic cytology of cervix can be made strong if normal cytology is known thoroughly. Cervical lining comprises three layers of squamous cells, the basal, intermediate, and superficial cells. Knowing the dimensions of these cells, especially the intermediate cells, helps to diagnose the squamous intraepithelial lesions accurately. Furthermore, recognizing the parabasal cells in the menopausal smears, either singly or as syncytial aggregates, is important to avoid overdiagnosis of squamous intraepithelial lesions. The other cell type in the cervical lining is the endocervical glandular epithelium. Exfoliated endocervical cells may at times resemble endometrial glandular cells. The morphology and differences between these two cell types have been highlighted. It is essential to recognize and report endometrial cells in women of 40 years and above according to the recent Bethesda System for Reporting Cervical Cytology. The squamous epithelium of cervix and vagina is highly sensitive to estrogen and progesterone hormones. Hence, the Pap smears, if desired, can help in evaluating the hormonal status of the woman. The ratio of parabasal, intermediate, and superficial squamous cells can help in calculating various maturation indices.

Indian Academy of Cytologists National Guidelines for Cytopathology Laboratories for Handling Suspected and Positive COVID-19 (SARS-CoV-2) Patient Samples.

COVID-19, caused by the SARS-CoV-2 virus, has been declared a pandemic by the World Health Organization. This scenario has impacted the way we practice cytopathology. Cytology laboratories receive fresh and potentially infectious biological samples including those from the respiratory tract, from COVID-19 positive or suspected patients. Hence, the Indian Academy of Cytologists thought it necessary and fit to bring forth appropriate guidelines starting from transportation, receipt, processing, and reporting of samples in the COVID-19 era. The guidelines are prepared with the aim of safeguarding and protecting the health care personnel including laboratory staff, trainees and cytopathologists by minimizing exposure to COVID-19 so that they remain safe, in order to able to provide a continuous service. We hope that these national guidelines will be implemented across all cytopathology laboratories effectively.

Can Fine Needle Aspiration Cytology be Used as a "Proxy Gold Standard" to Diagnose Tuberculous Mastitis?

OBJECTIVE: To assess the performance of fine needle aspiration cytology (FNAC) in the diagnosis of tuberculosis mastitis. MATERIALS AND METHODS: Diagnostic test performance evaluation using two methods-as compared to an alloyed gold standard as well as in the absence of a gold standard. Alloyed gold standard combined the results of acid fast bacilli in cytology smears, histopathological confirmation, and response to treatment. Bayesian estimation of test parameters was done in the absence of the gold standard. RESULTS: FNAC was carried out in 6,496 consecutive cases of breast lump and 104 cases of granulomatous mastitis were detected. Both methods of test parameter estimation identified a high specificity of FNAC for the diagnosis of tuberculosis mastitis (98.9% and 98.4%, respectively). Estimation of sensitivity was falsely high (100%) using the alloyed gold standard because of a workup bias and falsely low (8.41%) using the Bayesian estimation because of low prevalence. Likelihood ratios by both methods suggested that FNAC has good discriminatory capability. CONCLUSION: In situations where prevalence of tuberculosis is high and where facilities for histopathological evaluation do not exist, FNAC can offer an optional alternative to base the therapeutic decision for starting antitubercular treatment.

Interobserver agreement in the reporting of cervical biopsy specimens obtained from women screened by visual inspection with acetic acid and hybrid capture 2.

Visual inspection with acetic acid (VIA) and human papillomavirus detection have sensitivity higher than cytology but lower specificity. The high false-positive rate of either test poses a challenge to the colposcopists who obtain biopsies from the innocuous changes and to the pathologists who have to interpret large numbers of specimens that are either normal or have low-grade abnormalities. Interobserver variation in histopathologic interpretations of cervical punch biopsy specimens is high, specially for the lower-grade abnormalities. Use of the modified Bethesda system to report histology in place of the cervical intraepithelial neoplasia (CIN) system has the potential to reduce such variability as there are fewer categories. The present study aimed to assess the interobserver agreement to interpret cervical punch biopsies when both pathologists followed the modified Bethesda classification system and also when one pathologist followed the modified Bethesda classification system and the other followed the CIN classification system. Colposcopy-directed punch biopsies were obtained from VIA and/or Hybrid Capture 2-positive women. The Institute pathologist interpreted the slides using the CIN system. Blinded review was done by 2 external pathologists who independently interpreted cervical punch biopsies using the Bethesda system. The Institute pathologist's diagnoses based on CIN system were converted post hoc into categories belonging to the Bethesda system for comparison. The overall agreement was poor (κ=0.36). The lowest agreement was observed in the low-grade squamous intraepithelial lesion category (κ=0.23) and the highest in the squamous cell carcinoma category (κ=0.76). The agreement between the reviewers, both of whom used the Bethesda system, was substantial.

Ultrafast papanicolaou stain modified for developing countries: efficacy and pitfalls.

OBJECTIVE: To study the efficacy of the ultrafast Papanicolaou (UFP) staining technique for immediate cytologic diagnosis, to check specimen adequacy during radiologically guided fine needle aspiration cytology (FNAC) procedures and to objectively assess the quality of UFP stain and factors affecting it. STUDY DESIGN: Serial and random samples of cytologic material from 347 patients during a 2-year period were divided in 3 groups. Group I included 238 outpatient FNACs, group II included 59 radiologically guided FNACs, and group III included 50 cases of intraoperative cytology. After staining air-dried smears with UFP stain, immediate diagnosis was given. In group II, material adequacy was also conveyed to the radiologist. RESULTS: Overall diagnosis was possible in 297 (85.6%) cases. Only 8 (2.3%) cases could not be diagnosed due to staining difficulties. The overall concordance rate was 98%. Seventy-five percent of cases showed 'excellent' and 'good' morphology, allowing easy diagnosis. In 25% of 'fair' cases diagnosis was still possible, although with some difficulties. Factors affecting the quality of staining are discussed. CONCLUSION: The UFP staining technique is an accurate and reliable method for rapid cytology reporting. It significantly reduces total turn around time of the test result, thereby having the potential to be cost-effective, both for the patient and the hospital.

Comparative study of four candidate strategies to detect cervical cancer in different health care settings.

AIM: Considering the differing but potentially supplementary properties of visual inspection of the cervix with acetic acid (VIA) and the cytological examination (CYTO) of cervical smears for the screening of cervical cancers, we examined the performance of these two tests and their combinations for the screening of cervical cancer in different health care settings. METHODS: In this cross-sectional diagnostic test performance evaluation study of 4235 female subjects in the reproductive age group, we assessed the screening performance of four strategies: VIA alone, CYTO alone, VIA and CYTO combined in a parallel fashion, and VIA and CYTO combined in tandem. Subjects were recruited from three settings: Hospital, Urban Community and Rural Community. Colposcopy was used as the reference standard. Screening performance was assessed using sensitivity, specificity, post-test probabilities and likelihood ratios (LR), diagnostic odds, area under receiver operating characteristic curve and LR chi(2). RESULTS: Both VIA and CYTO when used alone had a low sensitivity but high specificity, especially in the Rural Community setting. A combination of the results of VIA and CYTO improved the diagnostic accuracy but the strategy using a parallel combination of VIA and CYTO was the most accurate. In general, all screening strategies using VIA and CYTO showed a modest screening performance. CONCLUSIONS: In the settings of varying levels of health care and low resources, caution is needed for a generalized use of VIA for cervical cancer screening. Further evaluation of the cost-effective ways of combining VIA and CYTO is needed in these circumstances.

Comparative study of fine needle aspiration and fine needle capillary sampling of thyroid lesions.

OBJECTIVE: To investigate whether fine needle capillary (FNC) sampling gives quantitatively and qualitatively superior cytologic material as compared to the conventional technique of fine needle aspiration (FNA) when performed by a single aspirator. STUDY DESIGN: Cross-sectional diagnostic test evaluation study. FNA and FNC were performed by a single operator on 200 diffuse and nodular thyroid lesions. RESULTS: A statistically significant difference in favor of FNC was observed for the parameter amount of cellular material. For the rest of the parameters--background blood or clot, degree of cellular degeneration, degree of cellular trauma and retention of architecture--the average score favored FNC but was not statistically significant--i.e., smears prepared from FNC displayed cellular material that was more concentrated, less damaged and less likely to be obscured by blood. CONCLUSION: Although FNC sampling was diagnostic in a greater number of cases than FNA sampling, this study did not prove a clear superiority of FNC over FNA. Until greater experience shows clear sampling superiority of FNC alone, rather than performing only FNA in diffuse or nodular thyroid lesions, incorporating FNC into the second puncture will definitely improve the quality and quantity of material at the patient's first visit.