References, Studies and Motivation

Literature and Studies

New encyclopaedic book from Dr. L. Szalay: Cervical Pathology, Colposcopy and Cytology

A new systematic review and meta-analysis shows: Liquid-based cervical cytology is neither more sensitive nor more specific for detection of highgrade cervical intraepithelial neoplasia compared with the conventional Pap test and the number of false-positve results is higher than with the conventional spatula Pap test.
Liquid Compared With Conventional Cervical Cytology. A Systematic Review and Meta-analysis. Marc Arbyn, MD, MSc, Christine Bergeron, MD, PhD, Paul Klinkhamer, MD, Pierre Martin-Hirsch, MD, PhD, Albertus G. Siebers, MSc, and Johan Bulten, MD, PhD. OBSTETRICS & GYNECOLOGY VOL. 111, NO. 1, JANUARY 2008
Evidence-Based Medicine Versus Liquid-Based Cytology
Trials That Matter: Liquid-Based Cervical Cytology: Disadvantages Seem to Outweigh Advantages 668  2007 American College of Physicians
Dr. Sawaya: Evidence-Based Medicine Versus Liquid-Based Cytology OBSTETRICS & GYNECOLOGY VOL. 111, NO. 1, JANUARY 2008
Lancet 2006; 367: 122–32:  Effect of study design and quality on unsatisfactory rates,cytology classifications, and accuracy in liquid-based versus conventional cervical cytology: a systematic review   Elizabeth Davey, Alexandra Barratt, Les Irwig, Siew F Chan, Petra Macaskill, Patricia Mannes, A Marion Saville
Jörg Obwegeser, Volker Schneider: Thin-layer cervical cytology: a new meta-analysis
J.H. Obwegeser, M.D., Does liquid-based technology really improve detection of cervical neoplasia?, Acta Cytologica 2001/709
J.H. Obwegeser, Was leistet die Dünnschicht-Zytologie wirklich? Erfahrungen aus einem Grosslabor in der Schweiz, Frauenarzt 44(2003)
The SZALAY CYTO-SPATULA meets all demands to a optimal cell sampler!
L. Szalay, M.D., Motivation for the development of the SZALAY CYTO-SPATULA
J. Jenny, M.D. 1995, GYNÄKOZYTOLOGIE, Einführung in die gynäkologische Zytodiagnostik
Rea Rammou-Kinia, M.D., Comparison of Spatula and Nonspatula methods for cervical sampling, Acta Cytologica 1991/35; abstract as pdf
Angelika Edtstadler, Zytotechnikerin, AKH Linz, Institut für Pathologie Abteilung Cytologie 1998, Criteria to introduce quality securing standards in gynaecological cytology
Special Issue on Cervicovaginal Cytopathology in Honor of George L. Wied on His 70th Birthday: VOL. 35 January-February 1991 of Acta Cytologica
The advantages of the SZALAY CYTO-SPATULA are extensively documented!
L. Szalay, M.D., CYTOLOGY OF THE UTERINE, This book contains more than 700 colored Pap test images!
M. Hilgarth M.D., L. Szalay M.D., GYNÄKOLOGISCHE ZYTODIAGNOSTIK, Colored atlas with ca. 400 Pap test images!



The following well known cytologists have been working with the SZALAY CYTO-SPATULA for many years. This list is not concluding!

Dr. G. Breitenecker, Wien
Dr. J. L. L'Eplattenier, Zürich
Dr. H. Flenker, Bremerhafen
Dr. J. Jenny, Zürich (verstorben am 23.12.2003)
Dr. J. Obwegeser, Zürich
Dr. U. Schenck, München
Dr. V. Schneider, Freiburg
Dr. L. Szalay, Gyor, Cervical Pathology Colposcopy and Cytology
C. Rodrigues, Cytologist FELLOW of the International Academy of Cytology, Zürich


Motivation for the development of the SZALAY CYTO-SPATULA

(Reprint from the book: CYTOLOGY OF THE UTERINE  Dr. L. Szalay)

The last few decades have not produced an universally accepted method for taking a smear. This is due to the fact that none of the implements devised to date allow a l00 % detection rate of cervical carcinoma or its precursors. In the United States and Western Europe the various spatulas based on Ayre's spatula are popular. None of the spatulas, however , has achieved the diagnostic yield desired.

Study of the histopathologic changes in the cervix reveals those abnormalities and factors which hinder or indeed prevent accurate sampling.



The ectocervix is visualized by the gynecologist. Many lesions can be localized by the colposcope but a large part of the endocervix is out of colposcopic range. Obtaining of smears with the cotton-tipped applicator from the endocervix is possible only when the diameter of the external os and cervical canal allow its passage. During the last two decades the local destructive therapy of ectocervical intraepithelial lesions has gained a wide acceptance (electrocoagulation, diathermy , cryo therapy and laser therapy). Partly as a consequence of this the squamo-columnar junction, which plays such a seminal role in the genesis of cervical carcinoma, is often relocated in the canal, as in the postmenopausal woman.

Fifteen to twenty per cent of intraepithelial lesions are found in the endocervix. Neither the colposcope, nor the traditional methods of cytologic sampling, ensure their early and accurate detection. This anatomic topography is one of the reasons why cases are always encountered in any practice when in spite of regular yearly colposcopic, cytologic and gynecologic screening, cervical carcinomas are discovered late. To evoke rapid tumor transit time as an explanation is not always plausible, as in such cases the screening of the endocervical mucus was defective. (Figs 1-3: endocervical carcinoma in situ. Figs 4-6: endocervical microinvasive and invasive carcinomas)



Traditional cytologic sampling results in smears composed of cells which have exfoliated from the most superficial layer of the epithelium. In some cases of high grade squamous intraepithelial lesion and invasive carcinoma special stains (Krutsay) reveal superficial keratinization which on occasion may form thick hyperkeratotic plaques. These not only prevent the spontaneous exfoliation of underlying neoplastic cells, but also form impermeable barriers for the cotton-tipped applicator, so that procuring of neoplastic cells becomes impossible.


The superficial layer in many cases of squamous intraepithelial lesions is parakeratotic. Although such cells exfoliate, the more deeply situated neoplastic cells will not appear in the smear.


The metabolic exchange and blood supply of the superficial portion of invasive carcinomas are precarious. This results in extensive cellular degeneration and necrosis. The covering necrotic blanket makes the deeper lying neoplastic cells unavailable for examination. Hence the relatively frequent false negative smears in cases of invasive carcinoma. Adenocarcinoma is even more prone to rapid autolysis and necrosis than squamous cell carcinoma. The surface of adenocarcinoma of the cervix which usually arises in the canal, tends to be necrotic and covered by mucus. Herein lies the explanation of the relatively infrequent detection of adenocarcinoma in situ and early invasive adenocarcinoma of the cervix.


  1. The surface epithelium covering cervical polyps may be normal but the glands underneath may have undergone neoplastic transformation. As a rule, spontaneously exfoliated cells in such cases are normal.
  2. Metastatic and non-epithelial tumors (such as sarcomas) can be diagnosed cytologically only when they invade and breach the covering squamous or columnar epithelium.

4. The range of Spatulas

The author of this atlas has also experienced several times the frustrating false negative smear. This stimulated the development of an improved spatula for smear taking. The new spatula devised differs in several aspects from its predecessors:

  1. The surface area of the ectocervix and the diameter and the length of the cervical canal differ between the nullipara and parous woman. Therefore a variety of spatulas were designed from which one of suitable size and shape may be chosen according to individual requirement.
  2. Since spontaneously exfoliated cells are not always representative of the whole lesion, rendering the surface of each spatula roughly allows removal of parakeratotic, hyperkeratotic and necrotic layers and ensures sampling of the underlying neoplastic cells.
  3. The elongated 'tongue' of the spatula ensures adequate scraping of the endocervical canal.

Links to this topic

The technique of smear taking with the SZALAY CYTO-SPATULA
Gynäkologie Zytologie: Einführung in die Zytodiagnostik
























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