Year : 2009 | Volume
: 52 | Issue : 4 | Page : 495--497
Evaluation of 100% rapid rescreening of cervical smears
Neelam Sood, Vikas Singh
Department of Pathology and Lab Medicine, Deen Dayal Upadhyay Hospital, Hari Nagar, New Delhi-110 064, India
B-3/337 Ground Floor, Paschim Vihar, Delhi-110 063
Advantage of rapid rescreening (RR) over conventional 10% random rescreening of all negative smears has been the topic of debate. RR of negative smears by cytopathologists/cytotechnologists have yielded good results. We undertook the rapid review of all the reported cervical smears to study its results as a means of strict quality control exercise on 2,500 smears.
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Sood N, Singh V. Evaluation of 100% rapid rescreening of cervical smears.Indian J Pathol Microbiol 2009;52:495-497
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Sood N, Singh V. Evaluation of 100% rapid rescreening of cervical smears. Indian J Pathol Microbiol [serial online] 2009 [cited 2021 Nov 30 ];52:495-497
Available from: https://www.ijpmonline.org/text.asp?2009/52/4/495/56134
A uniform categorization of Papanicalaou stain (PAP) smears by The Bethesda System 2001 is one way of ensuring quality results to reduce ambiguity in the smears reporting. Since cervical smear screening is bereft of its inherent limitation, strict quality control is an integral part of any successful cytopathology lab. A traditional way recommended was rescreening of 10% random negative smears but superiority of rapid rescreen of all negative smears has been emphasized by many workers. ,,,, Rapid rescreening (RR) refers to rapid low power review of the smears unsatisfactory/negative for a limited duration of time (30 sec to 1 min per smear). Suspect cases are studied later for a final diagnosis. There have been encouraging results from different workers. ,,,,
Materials and Methods
An internal quality control measure was undertaken in the form of RR to analyze false positives and negatives. A total of 2,500 cases from January 2006 till July 2008 for a period of 2 1 / 2 years were included in the study. All negative/unsatisfactory smears as well as all positive lesions were reevaluated and were upgraded/downgraded accordingly as per the Bethesda classification 2001 by cytopathologist. All smears were subjected to RR for a period of 1 min under 10Χ and suspected cases were kept aside for detailed evaluation later on. A review report was issued on all false negatives and followed up with follow up PAP smears and/or biopsies. All cervical biopsies and hysterectomies during this period were checked and co-related with RR findings. Histopathology was available of 2500 cases.
A total of 310 additional lesions (14.5%) were picked up on RR. Sixty seven smears were not evaluated further as were unsatisfactory. Of the 310 lesions picked up 170 (8.0%) showed infective etiology and 140 (5.75%) were reclassified as atypical squamous cell (ASC) and above [Table 1]. The most reclassified lesion on RR was low grade squamous intraepithelial lesion (LSIL) with and without human papilloma virus (HPV) changes 58/140 (41.40%), atypical squamous cell of undetermined significance (ASC-US) + ASC-US cannot rule out HSIL (ASC-H) 40/140 (28.6%) followed by atypical glandular cells of undetermined significance (AGUS) 22/140 (15.70%) and high grade squamous intraepithelial lesion (HSIL) 18/140 (12.9%). Two cases earlier classified as HSIL were re-categorized as squamous cell carcinoma (SCC).
Out of 2,500 cases screened, 167 were follow up PAP on different intervals. Amongst these 33 cases of ASCUS were picked up on RR in initial smears and showed cervical intraepithelial neoplasia (CIN) I in 8 cases (30%), 2 cases showed CIN II/III (8%) on 25 biopsies available [Figure 3].
Twenty two cases of AGUS were picked up on RR and biopsies were available in 10 cases. In 10 biopsies available for these cases, 3 showed CIN II/III, 1 showed adenocarcinoma, 4 showed mild atypia in the endocervical glands and 2 were negative [Figure 1]. Fifty eight cases of LSIL with or without HPV were detected on RR and histological diagnosis was available in 45 cases. 33 (73%) showed CIN I, 7 (15.5%) showed CIN II/III, and 5 (11.5%) were negative. 2/15 (13.33%) cases of biopsied HSIL showed CIN I and 1/15 (6.66%) showed adenocarcinoma and 12/15 (80%) showed SCC. It was observed that the false negatives were in those smears which were either hemorrhagic or thick or reported unsatisfactory earlier or with the paucity of the cellular material [Figure 2].
Random 10% negative smears have been subjected to full rescreening as an internal quality control measure. However, it has been subject of much criticism since it has no scientific basis and detects only a few false negative cases. , Computer assisted technologies are not a feasible option in developing countries with resource limited settings.  RR of all negative smears has been evaluated by many workers. , The sensitivity of RR is also dependent on duration of review, designation of the reviewer, and size of the batch of slides to be reviewed. , Yet the superiority of RR over conventional 10% screen has been emphasized. ,,
The system followed so far in our cytology labs was screening and reporting on negative smears by resident doctors and reporting of positive cases as well as random 10% screen by pathologists. RR was further modified to include all cases irrespective of positive, negative as well as unsatisfactory smears to further assess the benefit. As can be seen the infective pathology was additionally picked up in 14.5% of the cases with amended diagnosis. This brings the total infective cases to 54.8% which is comparable to 51.6% in Djemli series.  Twenty cases (0.8%) were upgraded to negative for intraepithelial lesion or malignancy (NILM) category from ASCUS and 2 cases of HSIL (0.08%) upgraded to NILM with reactive change and subsequent PAP smears were also negative.
ASC-US constituted 33/140 (23.5%) of the reviewed diagnosis which is comparable with 16.4% in Michelow  study, though it constituted 71% in Gupta series.  It is be noted that ASC-H has been included in the group of ASCUS in Gupta series while ASC-H has been put together with HSIL in Michelle series. , ASC-H comprised (7/140) 5% in our review cases. It is said that ASC-H should constitute 0.3-0.6% of all PAP tests and overall ASC-H constituted 0.5% in our series too.  Follow up biopsies were available in 25 cases and follow up PAP were available in 10 cases. Eight cases showed CIN 1 (30%) and 2 cases showed CIN 2/3 (8%) which is comparable with 26% in Gupta series [Table 2].  This is also comparable with reported 44.3% SIL or worse and 12% HSIL or worse in screening PAP tests (SPT) and 45% LSIL or worse and 13.3% HSIL or worse in diagnostic PAP tests (DPT). 
An additional 22 cases (15.7%) of AGUS was detected which is comparable with Michelow  (10%). Whereas 3.2% were confirmed malignant in Gupta series, 40% were confirmed malignancies in our series with available biopsies and subsequent PAP in 10/22 cases of AGUS.  100% showed malignancy in Deborah series, so it calls for a more vigilant and stricter criteria to label AGUS.  LSIL constituted 41.4% of RR cases vs. 20% in Gupta series vs. 43.1% of Michelow series. , Whereas 64% CIN I or above and 13.7% CIN 2/3 above were seen in LSIL follow up cases and 90% CIN I in Gupta series and cases in our series of LSIL had confirmed CIN I in 75% and CIN 2/3 in 15%. , HSIL constituted 12.9% in our reviewed diagnosis vs. 2.4% and 26% among the under diagnosed cases of Gupta. , However if ASC-H is include along with HSIL the rate is comparable with 30.5% in Michelow series. [3 ] Whereas 60-70% of HSIL have been confirmed as CIN 2/3 or above in SPT and DPT , 100% confirmation of HSIL has been reported in Gupta series and 100% confirmation was also seen in our series too. , Two out of 15 (13.3%) of biopsied HSIL showed CIN I, 1/15 (6.66%) showed adenocarcinoma, and 12/15(80%) showed SCC. Over all false negative rate was 5.6% which is comparable with 5.76% Michelow and 3.8 % Gupta. ,
As the aim is to reduce the false negatives, all efforts should be to done by introducing either a RR post screen by cytopathologist  or rapid pre screen.  It is also important to view ASC-H with great deal of concern, follow strict criteria,  view, and categorize this category with HSIL.  It is also important to screen hemorrhagic, paucicellular as well as thick smears with a vigilant eye before signing it out as negative as has been emphasized by other workers. 
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