Thames Valley Cytology Society
Volume 3 Issue 2	June 2000
NAC - 16th April 2000
Report by Marilyn Catlow, Watford General Hospital
This year's annual weekend conference at Warwick University focused largely on gynaecological cytology, and space allows me to select only a handful of topical issues covered. George Papanicolaou would have been gratified if he could have seen that 600 delegates (nearly half the membership of the NAC) attended, and that the usefulness of his life's work perseveres. The processing of samples, staining, and the observations and classifications that he recorded of stages towards malignant change in cells from the cervix now constitute thresholds embedded in digital technologies.
Dr David Leusley spoke on the treatment of cervical cancer and pressed for the embrace of new technologies. He criticised the paper chain delays between referral, getting an appointment, and being treated for cervical cancer by comparing it with electronically booking an overseas holiday which include complex timing issues, dealing in foreign languages and currency and air traffic control - all at the click of a mouse. With an objective of'survival with the least possible morbidity' he illustrated how, despite the fact that anything that can be put on the Internet is not refereed, that by using the net we are impacting via patients and bypassing lengthy established procedures. Three randomised controlled trials, using chemora-diation, as a new treatment for cervical disease were pre-published on the Internet, centralising an immediate sharing of new information. Each study showed significant (10-12%) improvement outcomes on survival and morbidity over conventional radiation + surgery.

Dr David Wilbur, on a visit from the USA, (who also spoke on located guided screening using Autopap systems) spoke on glandular abnormalities and related problems of 'benign mimickers' that constitute the AGUS category. He reminded us of the predictive cues for AIS, where low power identification shows rosettes and feathering, with reverse polarity, strips of pseudostratification, crowding, and apoptotic bodies. A raised N:C ratio, even chromatin with coarse granularity, enlarged elongated nucleus and micronucleoli are features for high power identification. Tubal metaplasia has cilia and terminal bars. Nuclei are often enlarged, pleomorphic and have a washed out appearance.

Dr Claire Eklund also from the USA spoke on the hidden side of liquid-based cytology. Her amusing account warned us to assess our needs first. A possible disincentive with starting up with thin-layer preps is the unexpected peripheral space requirements for consumables and waste disposal. This was cancelled out by the wonderful clarity of the final preps. She reassures us that if the cells do shrink it is proportional, and that all of the 'clues' are still there, and cell morphology is better because it is better preserved, (includes AIS). She concluded that ThinPrep is the preferred test and a medical necessity.

Prof. Ciaran Woodman spoke on the current thinking on HPV. With a connection between HPV and cervical cancer established, commercial interests are ready to capitalise. Another set of management dilemmas arise from incomplete understanding of the natural history of HPV and its 'temporal' development connected to SIL. 'Temporality' refers to the necessity that cause precedes the effect in time, and is the rationale for study populations. Results from his study population showed that HPV 16 was the most common infection, but many patients had many numeric types. New numeric types related to new sexual partners. Some types are more persistent than others - the longer the duration the higher the risk of CIN.

The incubation period for HPV association and an abnormal smear is very short - shorter than the recall interval. Following exposure to HPV16 the risk for CIN increased for 12-18 months and then declined. Where cytological abnormality disappears, but HPV of the same type persists, the woman is not more likely to develop further cytological abnormality. However, further cytological abnormality is associated with exposure to different types of HPV. Sloppy thinking is going on about the natural history of HPV and sexual activity. It is likely that everybody has been exposed to HPV. This weeks low risk type might be next weeks high risk type without a change of boyfriend, but because of the natural history of the virus, e.g. the vast majority of HPV16 are short-lived and transient, and it is misleading to focus on HPV 16 and 18.

Nick Budding and Eileen Hewer jointly presented findings of a study of rapid screening
techniques. The aims of the study was to identify best practice; to optimise time and technique; to compare pre-screen with re-screen; to explore cost effectiveness. Their study protocol was by questionnaire (to establish current practice), and make study visits to selected sites. The survey revealed wide variation on rapid screening practice. Time spent varied from 30 to 150 seconds. Patterns observed on study sites included :
1. 'step'(52%),
2. 'fast' whole slide (34%);
3. 'turret' (19%);.
4. 'random'(15%);
Every 'positive' slide in the slide bank used was a false negative, i.e. a true positive that had been missed. Slides were also contributed by study site laboratory. Each site was represented by 10 participants, who rapid screened 100 slides each, with a break at halfway. There was a high prevalence set and a low prevalence set. Responses included - no farther review; review; abnormal. Observations made were that time is subjective and that rapid screening 100 slides is tiring. Overall results - 58.2% of high grade abnormalities were identified. Pattern analysis showed that 'step1 pulled out the most. Screener performance was assessed on two loads of' 1st 50' and '2nd 50'. A higher percentage was pulled out in the 1st 50. 'Which individual' is also a variable - some are better at it than others. Conclusion: Step pattern probably is best. Workload limitation is desirable. Suitability of individuals for participation is an issue.

I love going to this meeting - where screeners, lab managers and medical, technical, and er-gonomic enthusiasts converge for social and professional exchanges. It seems to be increasingly attractive on a global level. It was a particular bonus for me this year that it was my name that was pulled out of the hat. One condition of the TVCS sponsorship is that if we want to attend the Banquet on the Saturday evening that we bear that cost personally. Well, it was worth every penny! Many thanks to you all.