References, Studies and Motivation

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

References

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

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.

1. ENDOCERVICAL ABNORMALITIES

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)

2. SUPERFICIAL EPITHELIAL CHANGES WHICH HINDER REPRESENTATIVE SAMPLING

Hyperkeratosis

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.

Parakeratosis

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.

Nekrosis

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.

3. NEOPLASTIC LESIONS COVERED BY NORMAL EPITHELIUM

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
http://www.quate.org/
Gynäkologie Zytologie: Einführung in die Zytodiagnostik

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