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Orres )Onc Ence Cited by Us Only As an Example J Clin Pathol 1994;47:569-571 569 ........................................... ............... ... ... -,,e,,. In advocating a low and high grade method of reporting, the Bethesda system is orres )onc ence cited by us only as an example. We accept ... ;.-,. ........... % ea that it is rather too elaborate. However, unlike Dr Slater, we hesitate to include J Clin Pathol: first published as 10.1136/jcp.47.6.569-a on 1 June 1994. Downloaded from Cytological changes preceding cervical nostic gold standard of CIN has partially "borderline changes", with wart virus and cancer collapsed, it is hard to believe that gynaeco- mild dyskaryosis as a low grade abnor- logical cytology can emerge unscathed. mality. Among cytopathologists "border- Dr Robertson and colleagues must be con- Which cytopathologist, with their hands on line" seems almost to have achieved the gratulated for holding up the "red flag of their hearts, can deny that accurate distinc- status of a diagnostic entity. Our experience classification" to the "bulls of gynaecologi- tion between borderline changes, wart virus, is that in practice it merely reflects uncer- cal cytology".' Their timing is excellent, and mild dyskaryosis is a difficult, often tainty in interpretation of a smear. particularly as the frailty of the current impossible, time consuming, and a largely Reparative changes in the cervix, papillo- reporting system becomes increasingly evi- pointless pursuit? These changes are all far mavirus infection, or atypical cells due to dent. more realistically grouped together as low inflammation can all present difficulties. A basic premise in the currently recom- grade abnormalities, requiring the same The latter may occasionally be confused mended terminology and management of clinical management. The hours saved by with invasive cancer, and a six month repeat cervical smears is that the degree of avoiding such mental contemplation would smear would be inappropriate. We feel that dyskaryosis correlates with the grade of be enormous. such reports should describe the diagnostic cervical intraepithelial neoplasia (CIN).23 We should not lose sight of the fact that difficulty, advise on further action, and be However, published information4 and the basic function of gynaeological cytology summarised as "no diagnosis". KC6 1 returns for the Department of Health is merely to screen for relevant disease that To the lay person the term "borderline" indicate that this is far from the case. will require subsequent histopathological is unsatisfactory. It could be quite frighten- Reasonable correlation occurs between diagnosis and clinical management. It must ing for some women, giving the impression severe dyskaryosis and CIN3, but consider- be seriously questioned whether the exis- of a limbo bordering on (?) the abyss. It is ably more variation is observed as the tence of multiple, closely related, diagnostic not a diagnostic entity and, like the unicorn degree of dyskaryosis and CIN diminishes. categories is warranted. Furthermore, it is which had similar problems of identity, Whether or not dyskaryosis and CIN should rumoured that this problem is about to be should be allowed to pass into mythology. correlate is debatable, as the definitions compounded by division of the category of involved are purely arbitrary. However, a borderline changes. Superficially, credibility principal reason why they do not must be for the existence of the current terminology the considerable interobserver variation in seems to be provided by the mass of statisti- the histopathological diagnosis of CIN.4s cal returns requested annually and the Health Service guidelines emphasise the requirement for these subtle distinctions to important requirement to compare cytol- be assessed in quality assurance schemes. It ogy and biopsy results.6 However, the cru- is also questionable as to whether this Pregnancy in von Willebrand's disease cial audit is whether cytological findings complex blinkered dogma should continue identify clinically relevant histopathological to be the staple of cytology training schools. The guidelines on the investigation and abnormalities and whether the false positive My proposition is simple: back to cyto- management of haemorrhagic disorders in rate is accordingly kept to a minimum. logical basics, before it is too late. pregnancy are welcome.' With reference Surprisingly, with only one or two excep- D SLATER to the management of von Willebrand"s Department ofHistopathology, tions,78 there has been little discussion with Rotherham Hospitals NHS Trust, disease, we have recently studied 23 regard to the possible introduction of the Moorgate Road, pregnancies managed at a single centre,2 American Bethesda system for reporting Rotherham S60 2UD and add the following comments. cervical smears.9 Indeed, some cynics We believe that there is a tendency 1 Robertson JH, Woodend B, Elliott H. http://jcp.bmj.com/ believe that any potential introduction was Cytological changes preceding cervical towards complacency in the management doomed following the timing of the publica- cancer. J7 Clin Pathol 1994;47:278-9. of pregnant women with von Willebrands tion, which coincided with the printing of 2 Evans DMD, Hudson EA, Brown CL, et al. disease due to an excessive reliance on Terminology in gynaecologial cytopatho- in the several million new HMR forms. However, logy: report of the Working Party of the improvement coagulation deficit. The although the Bethesda system uses the British Society for Clinical Cytology. Clin coagulation parameters improve in many terms low and high grade squamous Pathol 1986;39:933-44. instances, but we and others3 have noted intraepithelial lesions, its overall complexity 3 Evans DMD, Hudson EA, Brown CL, et al. exceptions, particularly in those more Management of women with abnormal and content is analogous to that of the cur- severely affected with low factor VIII cervical smears: Supplement to terminology on September 23, 2021 by guest. Protected copyright. rent British system. Accordingly, unlike Dr in gynaecological cytopathology. Clin (VIII:C)) before conception. In our series, Robertson, I share previous authors' views7 8 Pathol 1987;40:430-531. those patients with low baseline VIII:C 4 Robertson AJ, Anderson JM, Swanson Beck J, values (<15 IU/dl; four cases) had only that the Bethesda system has little to com- et al. Observer variability in histopatho- mend it. logical reporting of cervical biopsy limited improvement in VIII:C by the third I suspect that many gynaecological specimens. Clin Pathol 1989;42:231-8. trimester, the maximum attained being 5 Ismail SM, Colclough AB, Dinnen JS, et al. 54 IU/dl in the group. Bleeding times cytopathologists already perceive nuclear Observer variation in histopathological changes as either low or high grade abnor- diagnosis and grading of cervical intra- shortened significantly in only one of seven malities. It is therefore reassuring to see epithelial neoplasia. Br Med 1989;298: cases studied, and similar findings have that Dr Robertson's scientific conclusion 707-10. been noted by others.4 In addition, our 6 NHS Management Executive. Health Service supports this view. With little difficulty, cur- Guidelines HSG (93) 41. National Cervical observations support the view that type II rent national recommendations for termi- Screening PFrogramme 1993. London: DoH, patients carry a higher risk of primary post- nology and management of cervical smears 1993. partum haemorrhage (PPH) than type I 7 Hudson E. Cervical cytology. BMJ3 1990; type II v 0/12 type I). This could be amalgamated along the following 300:1353-4. patients (3/11 lines: 8 Robertson AJ, Hussein K, Swanson Beck J., seems to be independent of the value of Borderline changes, wart virus, and mild Cervical cytology. BMJ7 1990;301:122. VIII:C in the third trimester, and presum- dyskaryosis could be grouped together as 9 National Cancer Institute Workshop. The ably is explained by a failure of the primary 1988 Bethesda system for reporting low grade abnormalities. These would cervical/vaginal cytological diagnoses. haemostatic defect to improve in preg- necessitate a six month repeat smear and, if JAMA 1989;262:931-4. nancy. Importantly, secondary PPH persistent, require referral for colposcopy. occurred to a similar extent in both groups Moderate and severe dyskaryosis could Drs Robertson, Woodend, and Elliott comment: (2/12 type I and 3/11 type II-22% overall) be grouped together as high grade abnor- We agree with most of Dr Slater's com- and may be more dangerous as it often malities with the necessity for immediate ments, but would never have dared make occurs after discharge from hospital. referral for colposcopy. them. They draw attention to the The guidelines should serve to raise Gynaecological cytology has now become Emperor's new clothes and suggest rebel- awareness and maintain vigilance in the a nationalised industry with a propagated lion in the ranks. We also have long management of von Willbrand's disease aura of sophisticated diagnostic accuracy. regarded cervical cytology as a screening in pregnancy. We would add that This has resulted in undoubted success in procedure with little diagnostic precision with reference to secondary PPH, while the field of "cytology job and working party apart from its detection of severe the administration of prophylactic von creation schemes". However, as the diag- dyskaryosis. Willebrand factor (vWF) containing.
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