1. The Cytology Laboratory Chris Faraker Clinical Cytologist East Sussex Healthcare Trust

2. Cytology Staff & Roles Consultant Pathologists –HBPC co-ordinates aspects of programme –Report abnormal cytology Clinical Cytologists –Often manages laboratory –Report abnormal cytology Senior Biomedical Scientists –‘Checker’ of ? abnormal slides referred –Primary screening

3. Cytology Staff & Roles Biomedical Scientists –Primary screening –Laboratory practical work Cytology Screeners –Primary screening –Laboratory practical work Laboratory Assistants (MLA) –Sample preparation Office Staff –Data entry, result entry

4. Sample Flow Samples received by MLA –Checked for labelling/ST number etc –Form and specimen vial bar coded –Sent to BSUH for processing onto slides Brighton hub for slide prep for Sussex –ESHT, Worthing & Chichester ? Soon SASH –Could process 120 000 per year

5. ThinPrep ® 3000 Processor

6. ThinPrep LBC technology Dispersion Collection Transfer

7. Conventional vs ThinPrep

8. Sample Processing ThinPrep 3000 processes up to 60,000 specimens per year Racks of 80 vials take approx 2 hours to process. Places cells onto a slide ready for staining and screening T3000 reads each barcode and transfers the information to an LBC slide for that specimen Sample integrity BSUH have two processors

9. Sample Flow Slides returned to Conquest (or other spoke) Stained and prepared for screening by MLA Request forms data entry (90% ICE) and cytology and histology history printed Lab system history or Open exeter

10. Primary Screening By Cytoscreeners and BMSs 5 hours max microscopy Expect 5 000 to 8 000 per person per year Can report negative and inadequate samples Identify and mark suspect cells Pass ? abnormal slides to ‘Checker’

11. Abnormal Slides ‘Checker’ confirms abnormality and gives opinion ‘Checker’ may overrule screener and report as negative Passes confirmed abnormals to consultant reporter for final report

12. Internal Quality Control All negative and inadequate slides re- examined by another cytologist A ‘quick’ rescreen to check for abnormal cells missed in the original primary screen. Method developed in Hastings and Brighton in early 1990’s In 1995 became mandatory method of QC for NHSCSP laboratories

13. Results Paper copy sent to surgery or clinic Electronic reporting from lab system to surgery computer Electronic transfer of all results to PCSS PCSS sends result letters to women the next day

14. Colposcopy Direct Referral Reports recommending colposcopy sent automatically to colposcopy secretary Women should be seen in colposcopy: –within 8 weeks for borderline and mild dyskaryosis –within 4 weeks for moderate and severe dyskaryosis –within 2 weeks for ? Invasive or glandular abnormality

15. Laboratory Failsafe of Colposcopy Referral Check one month after referral that woman has been offered or has attended colposcopy (we have access to colposcopy database) If not, enquiry made to colposcopy secretary Further check made at month four. If still no attendance we require letter from colp sec returning woman to GP care

16. 14 Day Turnaround Previous target 80% in 4 weeks 100% in 6 weeks 14 days from sample collection to receipt of result A ‘vital sign’ from Jan 2011

17. 14 Day Turnaround Delays in Surgery Holding on for transport Inadequate completion of data – sample returned Delays in Laboratory Staff shortage Delay caused by outside processing Delays at PCSS Incorrect recall given All – Long bank holidays Next – HPV testing

18. 14 Day Turnaround

20. ESHT Audit of Rejected Tests 2010 195 of 13 200 rejected due to labelling errors or omissions (1.5%) 50% of these had no ST number The rest: –Unlabelled vial – will be reported inadequate and no slide will be made –Missmatch of details – DOB, Name etc –Insufficient information on form or vial –Vial -Name & DOB at least –Form- Name DOB Address at least + NHS number if possible

21. ESHT Rejected Test Audit Jul 10 – Jun 11 Returned for correction 68 Returned for ST number49 Unlabelled vial (discarded)67 Total184 0.74% of 25 000 samples

22. Request Forms Preferred requesting method is by ICE –Patient data linked to pathology system –Can scan forms for quicker data entry –ST number is a mandatory field –Cx visualised 5x360 sweep mandatory field Next preferred is OE prepopulated forms Least is blank handwritten forms

23. Technically Inadequate Samples Rate fluctuates: 1.6% to 2.6% over last 18 months No longer too thick, airdried or distorted But: –Excess blood in the vial –Too many polymorphs –Not enough cells –Blocking of filter –Lubricant –Cervical mucus –?Pessary etc

24. Conquest Inadequate Cytology

25. Laboratory Quality Assurance Cytologist screening sensitivities Monitored quarterly % of abnormal slides correctly detected at primary screening as assessed by rapid review NHSCSP Target All abnormalsmore than 90% High gradesmore than 95%

26. Laboratory Quality Assurance

27. Cytologist abnormal cytology detection rate –Percentage of high and low grade abnormalities detected over 6 months –Drop in rate may indicate screening errors

28. Laboratory Quality Assurance

29. Positive predictive value –reflects accuracy of a high grade report –percentage confirmed by biopsy NHSCSP target range74.2 – 90.3 % Conquest 2009-1087.8 %

30. Laboratory Quality Assurance External quality assessments –‘Test’ held twice yearly –Consultants, biomedical scientists & cytoscreeners –Mandatory participation –Set of 10 slides per round –Consultants must grade abnormality if present –Others must differentiate normal, abnormal and inadequate –Marking system – action taken if performance substandard

31. Laboratory Quality Assurance EQA of staining – four times per year CPA accreditation – 2 day inspection of standards, quality systems and performance –A requirement for NHSCSP laboratories QARC visit (inspections) –Laboratory and colposcopy standards

32. Human Papilloma Virus Over 100 subtypes – most do not cause disease Non oncogenic types 6, 11,42, 43, 44 (& 7 others) cause –Exophytic warts– condyloma acuminatum –Flat warts– koilocytotic atypia, flat condyloma, borderline cytology and mild dyskaryosis Oncogenic types 16, 18, 31, 33, 35, 36 and others cause cervical neoplasia (CIN, CGIN, Carcinoma)

33. HPV Testing To start 2011/2012 (i.e. before next April) Sept 1 st 2011 NHSCSP announced which technology may be used One testing centre for ESHT, WSHT, BSUH and SASH 1 st year low grade cytology triage 2 nd year Test of cure

34. HPV Triage Only 15-20% of women with LG cytology require treatment –(ESHT data 2009-2010: 24% referred to colposcopy with LG cytology had CIN 2 or worse) High Risk HPV testing would identify those in this group at risk of cervical neoplasia

35. HPV Triage If HR HPV negative then return to 3 yearly recall – 30% expected to have this outcome If positive then refer to colposcopy 46% of first borderlines and 83% of mild dyskaryosis are HR HPV positive 20% of those referred will require treatment

36. Test of Cure Follow up for HG CIN and CGIN is currently 10 years HR HPV test 6 months after treatment –Negative (even with LG cytology): low risk of residual neoplasia so routine 3 yearly recall –Positive or with HG cytology : colposcopy 75% of treated women returned to routine recall following TOC

37. Reporting and Follow up of Abnormalities (prior to HPV testing)

38. Management –Most regress but 21% (Conquest 2009-10 data) have high grade CIN –Repeat in 6/12 on first & second –On third refer for colposcopy –No more than 3 over 10yrs without referral –‘High grade borderline’ 49% (Conquest 2009-10 data) have high grade CIN - immediate referral Routine recall after 3 negative FU smears Borderline squamous

39. Mild Dyskaryosis After one mild dyskaryosis 40% of women have high grade CIN (one study) (Conquest 2009-10 data 25% referred for mild had CIN2+) Regression to normal after one mild is 25%. Management (local at present – may change) –Repeat in 6 months on first –Colposcopy on second –Referral on first if following treatment for CIN Routine recall after 3 negatives

40. Normal Cervix

41. HPV effect and Mild Dyskaryosis CIN 1

42. Moderate & severe dyskaryosis Predicts presence of CIN2 or CIN3 or worse Additional features may suggest carcinoma Management –1/3 of CIN3 become cancer in 10 years –Urgent colposcopic referral –ESHT direct referral system –FU post LLETZ – negative smears over ten years before return to routine recall – Test of cure High grade squamous dyskaryosis

43. CIN 3 extending into glands Severe Dyskaryosis

44. Invasive squamous carcinoma

45. Glandular neoplasia Endocervical cell dyskaryosis –In situ (CGIN) or invasive Manage as CIN3 if in-situ except FU samples must include endocervical cells. FU is best carried out in Colposcopy clinic (NHSCSP 20) Test of Cure not applicable to CGIN Endometrial adenocarcinoma Ovary, Tube etc

46. Endocervical dyskaryosis and CGIN

47. Ovarian carcinoma

48. Vault Cytology (not part of the screening programme PCSS will not issue results or recall women) On normal recall and no CIN in hysterectomy – no vault cytology NOT on normal recall and no CIN in hysterectomy – one vault cytology at 6 months then stop Histology shows CIN fully excised – vault cytology at 6 and 18 months Histology shows CIN incompletely or uncertainly excised – follow-up as if cervix still in situ ie 10 years for HG, 2 years for LG Cervical cancers – as directed by gynaecologist Non cervical cancers – no vault cytology

49. Endocervical brush An endocervical brush must never be used alone. It may be used in addition to the Cervex Brush in the following circumstances only: –There is difficulty inserting the Cervex Brush into a stenosed os –The woman is being followed up for borderline changes in endocervical cells –The woman is being followed up for treated glandular abnormality (CGIN) and a previous sample was inadequate due to the absence of endocervical cells Place both samples in a single vial