Home | About CytoJournalEditorial Board | Archived articles | Search CytoJ Articles | Subscribe | Peer review policies | CytoJournal Quiz Cases
  Reviewer corner | Author corner | OA Steward’s corner | CF member’s corner | Join as CF member | Manuscript submission | Open Access (OA) Advocacy
CytoJournal All 'FULL TEXT' in HTML are FREE under "open access" charter of CytoJournal.
To login for downloading any PDF OR to request TOC (Table of Content) by e-mail, please click here
Home Email this page Print this page Small font size Default font size Increase font size Cytopathology Foundation
Navigate here
 » Next article
 » Previous article 
 » Browse articles
Resource links
 »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »  Article in PDF (171 KB)
 »  Citation Manager
 »  Access Statistics
 »  Reader Comments
 »  Email Alert *
 »  Add to My List *
* Registration required (free)  

  In this article
 »  Abstract
 »  Background
 »  Guidelines in EBC
 »  Seeking evidence...
 »  Sampling and spe...
 »  Identify and int...
 »  Reporting
 »  Integrated appro...
 »  Role of open acc...
 »  Discussion and c...
 »  List of abbrevia...
 »  Competing interests
 »  References
 »  Article Figures
 »  Article Tables

 Article Access Statistics
    PDF Downloaded501    
    Comments [Add]    
    Cited by others 9    

Recommend this journal


CytoJournal 2007,  4:1

Time for evidence-based cytology

Department of Cytology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission30-Oct-2006
Date of Acceptance08-Jan-2007
Date of Web Publication08-Jan-2007

Correspondence Address:
Pranab Dey
Department of Cytology, Postgraduate Institute of Medical Education and Research, Chandigarh
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.1186/1742-6413-4-1

Rights and Permissions

 » Abstract 

Evidence-based medicine (EBM) is a fashionable and an extremely hot topic for clinicians, patients and the health service planners. Evidence-based cytology (EBC) is an offshoot of EBM. The EBC is concerned with generating a reproducible, high quality and clinically relevant test result in the field of cytology. This is a rapidly evolving area with high practical importance. EBC is based entirely on research data. The various professional bodies on cytology design and recommend guidelines on the basis of evidences. Once the guideline is implemented and practiced then the experiences of the practicing cytopathologists may be used as a feed back to alter the existing guideline. The various facets of EBC are sampling and specimen adequacy, morphological identification and computer based expert system, integrated reporting, identification of the controversial areas and high quality researches for evidences. It is the duty of the individuals and institutions to practice EBC for better diagnosis and management of the patients. In this present paper, the various aspects of EBC have been discussed.

How to cite this article:
Dey P. Time for evidence-based cytology. CytoJournal 2007;4:1

How to cite this URL:
Dey P. Time for evidence-based cytology. CytoJournal [serial online] 2007 [cited 2019 Nov 17];4:1. Available from: http://www.cytojournal.com/text.asp?2007/4/1/1/41222

 » Background Top

Evidence-based medicine (EBM) is a fashionable and an extremely hot topic for clinicians, patients and the health service planners. EBM is defined as "the conscientious, explicit and judicious use of current best evidence in making decision about the care of individual patients [1]. Evidence-based cytology (EBC) is an offshoot of EBM. The EBC is concerned with generating a reproducible, high quality and clinically relevant test result in the field of cytology. This is a rapidly evolving area with high practical importance. To the best of my knowledge, till now there is no article on evidence based cytology in English literature. In this present paper I have discussed the various aspects of EBC.

Increased demand for EBC

There is increased demand for EBC because of various reasons. There is massive explosion of knowledge in the medical science particularly in basic science. There are also many newer technologies and diagnostic modalities in hand. Therefore there is a need to integrate knowledge. There is also a massive increase of health care costs and overall workload. So it is necessary to make the best use of finite financial resources. The general patients are now more educated and have easier access to electronic media. So, they demand the best quality diagnostic tests in minimal period of time. Lastly there is increasing attention of the medico-legal problems in cytology. Practicing EBC may have some role in these areas.

EBC practice in clinical cytology laboratory

[Figure 1] highlights the overall view of EBC. There is need of good quality evidences in the field of cytology. These evidences should be derived from high quality research works. The basic data of cytology is handled by three branches of science, 1) statistics 2) epidemiology and 3) informatics. The team of experts should meet together periodically to make guidelines. These guidelines may be considered as the founder pillars of EBC. Based on the guidelines the EBC could be practiced.

 » Guidelines in EBC Top

There are various guidelines developed by different professional bodies for practicing EBC [2-5]. The guidelines may be opinion-based, consensus-based or evidence-based. In opinion based guidelines, one or more experts publish their recommendations which may or may not be opposed by others. In consensus-based guidelines, a group of experts meet and reach to a conclusive guideline. This is relatively rapid, inexpensive method and there may be potential bias in the recommendations [6,7]. Evidence-based guideline is the most desirable one. This is based on systematic identification, critical appraisal, and synthesis of evidences. Ideally, all the recommendations should be supported by enough evidences and the evidences should be analyzed before making guidelines. The most important or controversial questions should be dealt with great attention and systematic review should be done on that aspect. The method section of the guideline should be clearly described by the guideline development group. The member of a guideline development team should be from expert in the field of particular branch of cytology, clinicians, statistician, literature searcher and laboratory manager. The key to successful recommendation of guideline depends on multidisciplinarity of the guideline development team.

A guideline should always be realistic so that its implementation is possible. Evidence based guideline contains graded recommendation which is influenced by the strength of evidence and clinical judgments. If a recommendation is not supported by high grade evidence, then it should be based on consensus of the members [8].

 » Seeking evidences for evidence based cytology Top

Booth et al [9] in a review on evidence based pathology described the methods of evidence seeking techniques in general. However, these could be applied in the field of cytology. The first essential stage in evidence-seeking process is formulating or focusing our question/s. This will help us to use our search strategy on relevant database. Such as the question may be asked as "what will be the best re-screening method in conventional cervical cytology smear?". We can translate this question into a search strategy in the form of key words: "re-screening" AND "method" AND "cervical cytology". If we get systematic review or meta-analysis in the search result, then we can concentrate on these.

We can start with MEDLINE data base as the primary source followed by Cochrane Library and Health Technology Assessment database of the NHS Centre for reviews and dissemination

 » Sampling and specimen adequacy, and EBC Top

Sampling and specimen adequacy in cytology is an important aspect of EBC because the proper way of sample collection has great impact on the test result. It is also necessary to have adequate cells on the smear. There are various guidelines on the sampling and specimen adequacy by different expert committee [2-5, 10, 11] on respiratory specimen, urine, thyroid, breast and cervical smears. Table highlights the necessary instructions about the specimen collections in exfoliative cytology. The sensitivity of sputum cytology increases when the samples are obtained over five consecutive days [14,15]. However it has been noted that three consecutive specimens of sputum samples has reasonable sensitivity for detection of malignancies [16]. In microscopy, well preserved, well stained cytologic material with numerous alveolar macrophages are essential for adequate sputum [12]. Greenberg et al noted that adequacy of a sputum sample is directly proportional to the number of alveolar macrophages it contains [17]. Bronchial washings and brushings are complementary to sputum cytology in the diagnosis of respiratory tract lesions. The sample should be obtained from clinically suspicious area by repetitive installation of 3-5 ml sterile balanced salt solution through the bronchoscope. In general a large number of well preserved, optimally stained ciliated bronchial epithelial cells and macrophages are necessary to have a satisfactory specimen. However any specimen that contains cells or agents diagnostic of a pathologic agent should be considered as adequate [3]. The specimens which are heavily contaminated and obscured by oral squamous cells, blood, inflammatory cells or air drying artefacts should be labeled as unsatisfactory [3].

A voided urine specimen can be collected in any convenient time of the day, 3-4 hours after the patient last voided and approximately 100-300 ml of urine should be collected [2]. There is still no specific guidelines on the adequacy of urine sample. Papanicolaou's society of cytopathology practice guidelines task force believe that further studies should be done on adequacy of urine sample [2].

Accurate cervical sampling with the help of correct device/s is the most important part of an adequate cervical smear [18,19]. Inadequate sampling and sample transfer to the glass slides by the traditional or conventional method probably the major cause of false negative cytology [20]. The cytologic sampling of the cervix is taken by different people with different background. When sampling is faulty, the other part of the exercise such as examination and reporting on the specimen are in vain. The medical staff must receive appropriate training in taking cervical sampling. A close monitor of sample adequacy rate for each smear taker and regular feed back may improve the quality of the smear. In addition to properly collected sample, a relevant clinical data from history, inspection and palpation are also important.

The collection devices of cervical smear have great impact on adequacy of the materials [18]. A meta-analysis study showed that the widely used Ayre's spatula is the least effective device for cervical sampling and gives a lower yield of abnormal squamous cells [18]. Extended tip spatula along with cytobrush is the best combination of cervical sampling devise for adequate smear [18].

The Bethesda System, 2001 (TBS) tried to develop a standard framework on evaluation of specimen adequacy and reporting format [21]. According to TBS 2001, satisfactory samples should have the presence of endocervical cells/transformation zone (EC/TZ) component. There should be at least 10 well preserved endocervical or metaplastic squamous cells singly or in groups [Table 2] [21]. The assessment of the cellularity of the smears was also reconsidered in the meeting. The minimal squamous cellularity was suggested as 8000 to 12000 well-visualized squamous cells in conventional smears and 5000 squamous cells for liquid based preparations [22]. It seems that the counting of individual cells is clearly impractical. What may be the rationality of the presence or absence of endocervical cells related with sample adequacy? There are conflicting reports on the presence of EC/TZ cells on cervical smears and detection of squamous intraepithelial lesion (SIL) [23-26]. However, many retrospective longitudinal studies have demonstrated that lack of EC/TZ cells on smears do not have increase chance to develop SIL [7,25]. There may be variable presence of endocervical cells in woman who are pregnant, post menopausal or in oral contraceptives [28,29]. We should also remember that the identification of EC/TZ cells is also subjected to inter-observer variability [30]. Nevertheless, the regular feedback on EC/TZ cells may have value in improving overall specimen quality, and awareness of development and use of more sensitive collection technologies. It is expected that the changing incidence of cervical adenocarcinoma may alter the implication of EC/TZ sampling [31]. It is also important to note that other adequacy factors such as obscuring blood or inflammation, and excessive cytolysis should be evaluated in terms of their influence on sensitivity. Liquid based preparations may markedly reduce blood, inflammation or air drying effect along with less number of EC/TZ cells [32]. The number of endocervical cells and sqamous cells for adequacy in liquid based cytology are still a questionable issue.

Criteria for determining adequacy of FNAC of thyroid lesion is not settled till now and it varies from institution to institution [Table 3]. Papanicolaou Society of Cytopathology Task Forces on Standard of Practice has tried to solve this issue [4] but ultimately did not specify any numbers and groups of thyroid follicular epithelial cells for specimen adequacy. One group of investigators suggest that an adequate sample should contain five to six groups of well-preserved, well-visualized follicular cells with each group contains 10 or more cells [33]. Another group has opinion that ten clusters of follicular cells with at least 20 cells in each cluster are required to have adequate sample [34]. Whereas other suggest that at least six groups of follicular cells should be present on at least two of six aspirates of Fine needle aspiration cytology (FNAC) thyroid for considering adequate specimen [35]. The Papanicolaou Society of Cytopathology Task Forces on Standard of Practice admitted that the cellularity of a specimen is greatly influenced by nature of the lesion. Many cases of benign colloid goiter yield abundant colloid but few follicular cells and should not be considered as inadequate.

In September, 1996, the National Cancer Institute sponsored a conference to provide a uniform guideline to FNAC of breast [5]. The controversial topic of adequacy of breast FNA was discussed, but no specific comment was made on requirement for a minimum number of ductal cells for an adequate specimen. [Table 3]. The task has been transferred to the aspirator and reporting pathologist to judge the adequacy of the specimen. This particular issue has evoked much controversy in past [36,37]. Many studies have highlighted that the false negative FNAC of breast lesions have a low cellularity [36,38]. Therefore, many authors feel that the sample having minimum number of cells should be reported as non-diagnostic [39,40].

Till now to best of my knowledge, no such guideline has been set for FNAC of lymph node and other organs.

 » Identify and interpret: What is the role of expert system? Top

The tasks of cytopathologist are two folds: at first he should sort out the representative cells or cells of interest and second, he should objectively assess the morphologic alteration of the cells. When the cytopathologist is challenged to detect occasional abnormal cells in the midst of large number of normal cells, computer assisted screening may be helpful. The three different automated screening techniques were developed in the field of cervical cytology. These are PAPNET, AutoPap and AutoCyte Screen [41-46]. However, no such system is available commercially for exfoliative cytology or FNAC smears.

Human perception and interpretation are considered highly valuable in diagnostic interpretation. However it is of no doubt that human assessment of cytology smears and even histopathology sections are too some extent subjective and have very low inter-observer's agreement and low K value in certain situations [47-50]. Various computer based expert systems have been used for an objective approach in diagnosis [51-56]. Expert systems are computer programs that can perform reasoning tasks and can be used for diagnostic difficulties. These systems are based on Bayesian belief network (BBN), artificial neural net (ANN) works, and logistic regression analysis [51-56].

Bayesian belief networks (BBN) have been used by various authors [51,52] to diagnose the cases of benign and malignant lesions in FNAC of breast lesions. The ability of the BBN was satisfactory in diagnosis decision making. It was concluded that this expert system can help in consistent and objective diagnosis of breast lesions.

Another group of researchers [53] investigated the potential of the ANN for the discrimination of benign from malignant breast lesions. This neural network showed excellent performance for correct classification of cells.

The potential of back propagation neural networks in the discrimination of benign from malignant thyroid lesions were examined by Karakitsos P, et al [54]. It was concluded that use of ANN may improve the diagnostic accuracy of FNA of the thyroid gland, especially in cases classified as suspicious for malignancy.

The potential value of morphometry and ANN for discriminating benign from malignant nuclei and lesions of the lower urinary tract on images of routinely processed voided urine smears were investigated by Karakitsos P et al [55]. Application of ANN offered good classification at the nuclear and patient level and promised to become a powerful tool for everyday practice in the cytologic laboratory.

Another group of researchers investigated the potential value of morphometry and the back propagation neural network for the discrimination of benign and malignant lesions in images of routinely processed gastric smears stained by the Papanicolaou technique [56]. Their results indicate that ANN and image morphometry may offer useful information about the potential for malignancy in gastric cells.

This type of expert based system is valuable however the professional societies of the pathologists and cytopathologists should take active participation in designing, evaluating and modifying such systems.

 » Reporting Top

Reporting is one of the important components of generation of a test result. Optimum content and format of the report are necessary for appropriate communication with the clinicians and the patient. There are various guidelines on the diagnostic entities in exfoliative and fine needle aspiration cytology [2-5]. [Table 1], [Table 2],[Table 3].Reporting formats can be in the form of check list type i,e proforma report or descriptive report or computer generated. Pathologist should be extremely careful about the terminology or phases to express the certainty. Certain phrases such as "suggestive of", "consistent with", "possibly" etc. should be carefully used. Indiscriminate use of the phrase may generate confusion to the clinician [57].

 » Integrated approach of reporting Top

In recent days, there is massive advancement in the field of molecular biology and computer technology. The massive explosion of knowledge has also significant impact on cytologists. Along with cytomorphology of a lesion, the cytologists now have the information of immunocytochemistry, biochemical profiles and molecular details. So a pan-diagnostic approach is needed [58], which will be in other word a morpho-molecular approach to tissue diagnosis. The cytopathologist will have to combine the clinical history of the disease with the cytomorphology, immunocytochemical findings and molecular details for precise diagnosis. In future, such "molecular cytopathologist" will play a central role in clinical decision making.

 » Role of open access article Top

Open access extends benefits of easy access for the readers and wider real time dissemination of research areas in cytology for the authors-researchers. Some of the benefits of open access and comparison with conventional method of publishing scientific knowledge are depicted in a comic strip published previously [59]. The great benefits of online open access journal are rapid turn around time, real time publications and significant cost savings. The open access journal helps in free flow of scientific information which is immensely important for diagnosis and management of diseases [59]. To avoid publication of misguided substandard or faulty research, peer review of every article is strongly favored [60]. Cytojournal is a peer reviewed cytopathology journal which plays an important role in publishing good quality research data in cytopathology in open access [61]. The research articles are accessible to any one from any part of the world independent of the financial budget of the readers [62]. The online nature allows interactive real time participation. The reader can express their opinion immediately on any article and this has definite positive impact on future of evidence based cytology with wider participation.

 » Discussion and conclusion Top

EBC is based entirely on evidences which should be of good quality. There are many publications which have described how to generate bias free good quality evidences from a research work [63-65]. The good quality research studies can be produced by appropriate study design of the work, explicit identification of the question, appropriate choice of sample population, application of ideal reference standard both to the test and control population, blind comparison of method against reference and outcome, exclusion of confounding variables and introducing reproducible methodology. The ultimate fate of the research work is publication and there may be potential bias in the publication of result because there is greater chance of publication of positive findings [66]. This also should be avoided as far as possible.

The various professional bodies on cytology design and recommend guidelines on the basis of evidences. We also should keep in mind that there is no guarantee that these guidelines will be followed by the practicing cytologists [67]. It is the responsibilities of the individuals or institutions to follow the most accepted guidelines. Once the guideline is implemented and practiced then the experiences of the practicing cytopathologists may be used as a feed back to alter the existing guideline.

Systematic review is also very important in EBC. It is usually moderately comprehensive and summarizes all relevant research information. It identifies various limitations in methodologies of different studies and also helps to limit bias. Systematic review helps to enhance confidence in overall result and also reduces delay between discovery and implementation of the knowledge. At the end it identifies new research questions [68]. However systematic review may provide insufficient data. It is important to find out that whether a comprehensive and explicit search strategy has been used in the review or not? The quality of the included studies in the review is also important.

The other aspect of the EBC is to employ computer based expert system. This is in early stage of development. The professional body of cytology can take part active role for proper designing and application of these systems. Standard algorithm of reporting format may also help in diagnosis [69]. There should be large number of digital pictures available in internet web pages for guidance of diagnosis. Telepathology may also be helpful in diagnosis of difficult cases.

The controversial areas of cytology should be identified and multi-institutional, multinational high quality research works should be done. The result of these researches should be available to all. Open access journals can play an important role for dissemination of knowledge. In fact, there are many articles in Cytojournal on thyroid FNAC, Anal pap, lymph node FNAC, urine cytology, liver etc which probably bears good impact to the cytopathology society [70-74].

It is of no doubt that the use of a diagnostic test is an intervention [75] and the outcome of the cytologic test is part of the decision making process that lead to an improved outcome in clinical context. So we can say that a cytologic test may improve the overall diagnostic process, therapeutic strategy, and economic benefit. In fact it is an integral part of evidence-based medicine. However, it is interesting to note that evidence-based medicine appears to have very little impact in the field of cytology. Probably it is now the ideal time to integrate our information in more productive way for better diagnosis and management of the patients. This is the right time to practice evidence based cytology.

 » List of abbreviations used Top

EBM = Evidence-based medicine

EBC = Evidence-based cytology

TBS = The Bethesda System

EC/TZ = Endocervical cells/transformation zone

FNAC = Fine needle aspiration cytology

BBN = Bayesian belief network

ANN = Artificial neural net

 » Competing interests Top

The author(s) declare that they have no competing interests.

 » References Top

1.Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it is not. BMJ 1996, 312: 71-72.  Back to cited text no. 1    
2.Layfield LJ, Elsheikh TM, Fili A, Nayar R, Shidham V: Review of the state of the art and recommendations of the Papanicolaou society of cytopathology for urinary cytology procedures and reporting. The Papanicolaou society of cytopathology practice guidelines task force. Diagn Cytopathol 2003, 30: 24-30.  Back to cited text no. 2    
3. Papanicolaou society of cytopathology task force on standards of practice. Guidelines of the Papanicolaou society of cytopathology for the examination of cytologic specimens obtained from the respiratory tract Diagn Cytopathol 1999, 21: 61-69.  Back to cited text no. 3    
4. The Papanicolaou society of cytopathology task force on standards of practice. Guidelines of the Papanicolaou society of cytopathology for the examination of fine needle aspiration specimens from thyroid nodules Diagn Cytopathol 1996, 15: 84-89.  Back to cited text no. 4    
5.Bibbo M, Abati A: The uniform approach to breast fine needle aspiration biopsy. Acta Cytol 1996, 40: 1119-1126.   Back to cited text no. 5    
6.Woof SH, Grol R, Hutchinson A, Eccles M, Grimshaw J: Potential benefits, limitations, and harms of clinical guidelines. BMJ 1999, 318: 527-530.   Back to cited text no. 6    
7.Watine J: Are laboratory investigations recommended in current medical practice guidelines supported by available evidences? Clin Chem Lab Med 2002, 40: 252-255.  Back to cited text no. 7    
8.Scottish Intercollegiate Guidelines Network (SIGN): Grading system for recommendations in evidence based clinical guidelines. [] Report of a review of the system for grading recommendations in SIGN guidelines Edinburgh: Scottish Intercollegiate Guidelines Network; 2000.   Back to cited text no. 8    
9.Booth A: Mapping the evidence base of pathology. J Pathol 1999, 188: 344-350.  Back to cited text no. 9    
10.Solmon D, Davey D, Kurman R, Moriarty A, O'Connor D, Prey M, Rabb S, Sherman M, Wilbur D, Wright T, Young T: The 2001 Bethesda System. Terminology for reporting results of cervical cytology. JAMA 2002, 287: 2114-2119.  Back to cited text no. 10    
11.]   Back to cited text no. 11    
12.Bocking A, Biesterfeld S, Chatelain R, Gien-Gerlach G, Esser E: Diagnosis of bronchial carcinoma on sections of paraffin-embedded sputum. Sensitivity and specificity of an alteration to routine cytology. Acta Cytol 1992, 36: 37-47.  Back to cited text no. 12    
13.Johnston WW: Fine needle aspiration biopsy versus sputum and bronchial material in the diagnosis of lung cancer: a comparative study of 168 patients. Acta Cytol 1998, 32: 641-648.   Back to cited text no. 13    
14.Erozan YS, Frost JK: Cytopathologic diagnosis of lung cancer. Semin Oncol 1974, 1: 191-198.  Back to cited text no. 14    
15.Koss LG, Melamed MR, Goodner JT: Pulmonary cytology: a brief survey of diagnostic results from July 1 st , 1952 until December 31 st , 1960. Acta Cytolo 1964, 8: 104-113.   Back to cited text no. 15    
16.Johnston WW: Ten years of respiratory cytopathology of Duke University Medical Center III. The cytopathologic diagnosis of lung cancer during the year 1970 to 1974 noting the significance of specimen number and type. Acta Cytol 1981, 25: 103-107.   Back to cited text no. 16    
17.Greenberg SD: Recent advances in pulmonary cytopathology. Hum Pathol 1993, 14: 901-912.   Back to cited text no. 17    
18.Martin-Hirsch P, Lilford R, Jarvis G, Kitchener HC: Efficacy of cervical smear collection devices: a systematic review and meta-analysis. Lancet 1999, 354: 1763-1770.  Back to cited text no. 18    
19.[]  Back to cited text no. 19    
20.Mc Googan E, Colgan TJ, Ramzy I, et al .: Cell preparation methods and criteria for sample adequacy. IAC Task force summary. IAC TASK FORCE NO 21. Acta Cytol 1998, 42: 25-32.   Back to cited text no. 20    
21.Smith JHF: Bethesda 2001. Cytopathology 2002, 13: 4-10.  Back to cited text no. 21    
22.[]  Back to cited text no. 22    
23.Vooijs GP, Elias A, van der Graaf Y: The influence of sample takers on the cellular composition of cervical smears. Acta Cytol 1986, 30: 251-257.   Back to cited text no. 23    
24.Young W: Comparison of transformation zone sampling rates - a potentially useful indicator of smear taker performance. Cytopathology 2000, 11: 116-223.   Back to cited text no. 24    
25.Kivlahan C, Ingram E: Papanicolaou smears without endocervical cells: are they inadequate? Acta Cytol 1986, 30: 258-260.   Back to cited text no. 25    
26.Sidawy MK, Tabbara SO, Silverberg SG: Should we report cervical smears lacking endocervical component as unsatisfactory? Diagn Cytopathol 1992, 8: 567-570.  Back to cited text no. 26    
27.Mitchell H: Longitudinal analysis of histologic high grade disease after negative cervical cytology according to endocervical status. Cancer (Cancer Cytopathol) 2001, 93: 237-240.   Back to cited text no. 27    
28.Humblin JE, Brock CD, Litchfield L: Papanicolaou smear adequacy: effect of different techniques in specific fertility states. J Fam Pract 1985, 20: 257-260.   Back to cited text no. 28    
29.Lee D, Wheelock JB, Patrissi GA: Endocervical cell recovery. Mil Med 1992, 157: 1-4  Back to cited text no. 29    
30.Klinkhamer PJJ, Vooijs GP, de Haan AFJ: Intraobserver and interobserver variability in the quality assessment of cervical smears. Acta Cytol 1989, 33: 215-218.   Back to cited text no. 30    
31.Stockton D, Cooper P, Lonsdale RN: Changing incidence of invasive adenocarcinoma of the uterine cervix in East Anglia. J Med Screen 1997, 4: 40-43.   Back to cited text no. 31    
32.Luthra UK, Chishti M, Dey P, Jolly SV, Abdulla M, Das DK: Performance of ThinPrep smear method in a Gynaecology outpatient setting in Kuwait. Acta Cytol 2002, 46: 303-310.   Back to cited text no. 32    
33.Goellner JR, Gharib H, Grant CS, Johnson DA: Fine needle aspiration cytology of the thyroid, 1980 to 1986. Acta Cytol 1987, 31: 587-590.   Back to cited text no. 33    
34.Nguyen GK, Ginsberg J, Crockford PM: Fine needle aspiration biopsy cytology of the thyroid. Its value and limitations in the diagnosis and management of solitary thyroid nodules. Pathol Annu 1991, 26: 63-91.   Back to cited text no. 34    
35.Hamburger JI, Husain M: Semiquantitative criteria for fine needle aspiration biopsy diagnosis: Reduced false-negative diagnosis. Diag Cytopathol 1988, 4: 14-7.   Back to cited text no. 35    
36.Layfield LJ, Mooney EE, Glaskow B, Hinchowitz S, Coogan A: What constitutes an adequate smear in needle aspiration cytology of the breast? Cancer Cytopathol 1997, 81: 16-21.   Back to cited text no. 36    
37.Abati A: To count or not to count? A review of the issue of adequacy of breast FNA. Diag Cytopathol 1999, 21: 142-147.   Back to cited text no. 37    
38.Sneige N: Should specimen adequacy be determined by the opinion of the aspirator or by the cells on the slides. Cancer Cytopathology 1997, 81: 3-5.   Back to cited text no. 38    
39.Abendroth CS, Wang HH, Ducatman BS: Comparative features of carcinoma in situ and atypical ductal hyperplasia of the breast on fine-needle aspiration biopsy specimens. Am J Clin Pathol 1991, 96 (5) : 654-9.  Back to cited text no. 39    
40.Sneige N, Staerkel GA, Caraway NP, Fanning TV, Katz RL: A plea for uniform terminology and reporting of breast fine needle aspirates. M.D. Anderson Cancer Center proposal. Acta Cytol 1994, 38 (6) : 971-2.   Back to cited text no. 40    
41.Mango LJ, Radensky PW: Interactive Neural network-assisted screening: A clinical assessment. Acta Cytol 1998, 42: 233-245.  Back to cited text no. 41    
42.Ashfaq R, Sailger F, Solares B, Thomas S, Liu G, Liang Y, Saboorian MH: Evaluation of the PAPNET system for prescreening triage of cervicovaginal smears. ? Acta Cytol 1997, 41: 1058-1064.   Back to cited text no. 42    
43.Rosenthal DL, Acosta D, Peters RK: Computer-assisted rescreening of clinically important false negative cervical smears using the PAPNET testing system. Acta Cytol 1996, 40: 120-126.  Back to cited text no. 43    
44.Fetterman B, Pawlick G, Koo H, Hartinger J, Gilbert C, Connell S: Determining the utility and effectiveness of the NeoPath AutoPap 300 QC system used routinely. Acta Ctol 1999, 43: 13-22.   Back to cited text no. 44    
45.Wilbur DC, Prey MU, Miller WM, Pawlick GF, Colgan TJ: The AutoPap system for primary screening in cervical cytology. Comparing the results of a prospective, intended use study with routine manual practice. Acta Cytol 1998, 42: 214-220.   Back to cited text no. 45    
46.Wilbur DC, Bonfiglio TA, Rutkowski MA, Atkison KM, Richart RM, Lee JS, Patten SF: Sensitivity of the AutoPap 300 QC system for cervical cytologic abnormalities. Biopsy data cofirmation. Acta Cytol 1996, 40: 127-132.   Back to cited text no. 46    
47.Bosman FT: Dysplasia classification: pathology in disgrace? J Pathol 2001, 194 (2) : 143-4.   Back to cited text no. 47    
48.Clary KM, Silverman JF, Liu Y, Sturgis CD, Grzybicki DM, Mahood LK, Raab SS: Cytohistologic discrepancies: a means to improve pathology practice and patient outcomes. Am J Clin Pathol 2002, 117 (4) : 567-73.  Back to cited text no. 48    
49.de Vet HC, Knipschild PG, Schouten HJ, Koudstaal J, Kwee WS, Willebrand D, Sturmans F, Arends JW: Interobserver variation in histopathological grading of cervical dysplasia. J Clin Epidemiol 1990, 43 (12) : 1395-8.   Back to cited text no. 49    
50.Dalton LW, Page DL, Dupont WD: Histologic grading of breast carcinoma. A reproducibility study. Cancer 1994, 73 (11) : 2765-70.   Back to cited text no. 50    
51.Whimster WF, Hamilton PW, Anderson NA, Humphreys S, Boyle M, Sundaresan M, Rainey A, Giles A, Hopster D, Bartels PH: Reproducibility of Bayesian belief network assessment of breast fine needle aspirates. Anal Quant Cytol Histol 1996, 18 (4) : 267-74.   Back to cited text no. 51    
52.Hamilton PW, Anderson N, Bartels PH, Thompson D: Expert system support using Bayesian belief networks in the diagnosis of fine needle aspiration biopsy specimens of the breast. J Clin Pathol 1994, 47 (4) : 329-36.  Back to cited text no. 52    
53.Markopoulos C, Karakitsos P, Botsoli-Stergiou E, Pouliakis A, Ioakim-Liossi A, Kyrkou K, Gogas J: Application of the learning vector quantizer to the classification of breast lesions. Anal Quant Cytol Histol 1997, 19 (5) : 453-60.  Back to cited text no. 53    
54.Karakitsos P, Cochand-Priollet B, Guillausseau PJ, Pouliakis A: Potential of the back propagation neural network in the morphologic examination of thyroid lesions. Anal Quant Cytol Histol 1996, 18 (6) : 494-500.  Back to cited text no. 54    
55.Karakitsos P, Pouliakis A, Kordalis G, Georgoulakis J, Kittas C, Kyroudes A: Potential of radial basis function neural networks in discriminating benign from malignant lesions of the lower urinary tract. Anal Quant Cytol Histol 2005, 27 (1) : 35-42.  Back to cited text no. 55    
56.Karakitsos P, Stergiou EB, Pouliakis A, Tzivras M, Archimandritis A, Liossi AI, Kyrkou K: Potential of the back propagation neural network in the discrimination of benign from malignant gastric cells. Anal Quant Cytol Histol 1996, 18 (3) : 245-50.   Back to cited text no. 56    
57.Attanoos RL, Bull AD, Douglas-Jones AG, Fligelstone LJ, Semararo D: Phraseology in pathology reports: a comparative study of interpretation among pathologists and surgeons. J Clin Pathol 1996, 49: 79-81.   Back to cited text no. 57    
58.Salto-Tellez M, Koay ES: Molecular diagnostic cytopathology: definitions, scope and clinical utility. Cytopathology 2004, 15 (5) : 252-5.   Back to cited text no. 58    
59.Shidham VB, Sandweiss L, Atkinson BF: First CytoJournal Peer-Reviewer's Retreat in 2006 - Open access, peer-review, and impact factor. CytoJournal 2006, 3: 5. doi:10.1186/1742-6413-3-5  Back to cited text no. 59    
60.Hofer TP, Asch SM, Hayward RA, Rubenstein LV, Hogan MM, Adams J, Kerr EA: Profiling quality of care: Is there a role for peer review? BMC Health Serv Res 2004, 19;4 (1) : 9.   Back to cited text no. 60    
61.[]  Back to cited text no. 61    
62.Shidham VinodB, Cafaro Anthony, Atkinson BarbaraF: CytoJournal joins 'open access' philosophy. CytoJournal 2004, 1: 1. (29 July 2004)  Back to cited text no. 62    
63.Greenhalgh T: How to read a paper: papers that report diagnostic or screening tests. Br Med J 1997, 315: 540-543.   Back to cited text no. 63    
64.Mulrow CD, Linn WD, Gaul MK, Pugh JA: Assessing quality of a diagnostic test evaluation. J Gen Intern Med 1989, 4: 288-295.   Back to cited text no. 64    
65.Jaeschke R, Guyatt G, Sackett DL: Users' guides to the medical literature. III. How to use an article about a diagnostic tests. A. Are the results of the study valid? Evidence-Based Medicine Working Group. JAMA 1994, 271: 389-391.  Back to cited text no. 65    
66.Easterbrook PJ, Berline JA, Gopalan R, Matthews DR: Publication bias in clinical research. Lancet 1991, 337: 867-872.   Back to cited text no. 66    
67.Tabbara SO, Frost AR, Stoler MH, Sneige N, Sidawy MK: Changing trends in breast fine-needle aspiration: results of the Papanicolaou Society of Cytopathology Survey. Diagn Cytopathol 2000, 22 (2) : 126-30.   Back to cited text no. 67    
68.Price CP: Evidence-based Laboratory Medicine: Supporting Decision-Making. Clinical Chemistry 2000, 46: 1041-1050  Back to cited text no. 68    
69.Cross SS, Stephenson TJ, Mohammed T, Harrisont RF: Validation of a decision support system for the cytodiagnosis of fine needle aspirates of the breast using a prospectively collected dataset from multiple observers in a working clinical environment. Cytopathology 2000, 11 (6) : 503-12.   Back to cited text no. 69    
70.Nguyen G-K, Lee MW, Ginsberg J, Wragg T, ilodeau DB: Fine-needle aspiration of the thyroid: an overview. CytoJournal 2005, 2: 12.doi:10.1186/1742-6413-2-12  Back to cited text no. 70    
71.Arain S, Walts AE, Thomas P, Bose S: The Anal Pap Smear: Cytomorphology of squamous intraepithelial lesions. Cytojournal 2005, 16;2 (1) : 4.   Back to cited text no. 71    
72.Dey P, Amir T, Al Jassar A, Al Shemmari S, Jogai S, Bhat MG, Al Quallaf A, Al Shammari Z: Combined applications of fine needle aspiration cytology and Flow cytometric immunphenotyping for diagnosis and classification of non Hodgkin Lymphoma. Cytojournal 2006, 27;3: 24.   Back to cited text no. 72    
73.Bhatia A, Dey P, Kakkar N, Srinivasan R, Nijhawan R: Malignant atypical cell in urine cytology: a diagnostic dilemma. Cytojournal 2006, 15;3 (1) : 28.  Back to cited text no. 73    
74.Wee A: Fine needle aspiration biopsy of the liver: Algorithmic approach and current issues in the diagnosis of hepatocellular carcinoma. CytoJournal 2005, 8;2: 7.   Back to cited text no. 74    
75.Lundberg GD: The need for an outcomes research agenda for clinical laboratory testing. JAMA 1998, 280: 565-566.  Back to cited text no. 75    


  [Figure 1]

  [Table 1], [Table 2], [Table 3]

This article has been cited by
1 Chronic lymphocytic thyroiditis: could it be influenced by a petrochemical complex? Data from a cytological study in South-Eastern Sicily
S. Arena,A. Latina,R. Baratta,G. Burgio,D. Gullo,S. Benvenga
European Journal of Endocrinology. 2015; 172(4): 383
[Pubmed] | [DOI]
2 Evidence-based cytology in veterinary medicine: progress and opportunities
Leslie C. Sharkey
Veterinary Clinical Pathology. 2012; 41(3): 305
[Pubmed] | [DOI]
3 Diagnostic Cytology in Veterinary Medicine: A Comparative and Evidence-Based Approach
Leslie C. Sharkey,Maxey L. Wellman
Clinics in Laboratory Medicine. 2011; 31(1): 1
[Pubmed] | [DOI]
4 Diagnostic Cytology in Veterinary Medicine: A Comparative and Evidence-Based Approach
Sharkey, L.C., Wellman, M.L.
Clinics in Laboratory Medicine. 2011; 31(1): 1-19
5 Mean nuclear volume in complex atypical hyperplasia and adenocarcinoma of the endometrium
Kaur, J., Dey, P.
Analytical and Quantitative Cytology and Histology. 2010; 32(5): 291-294
6 Comparative validation of c-kit exon 11 mutation analysis on cytology samples and corresponding surgical resections of gastrointestinal stromal tumours
Pang, NKB and Chin, SY and Nga, ME and Chang, AR and Ismail, TM and Omar, SS and Charlton, A. and Salto-Tellez, M.
Cytopathology. 2009; 20(5): 297-303
7 Comparative validation ofc-kitexon 11 mutation analysis on cytology samples and corresponding surgical resections of gastrointestinal stromal tumours
N. K. B. Pang,S. Y. Chin,M. E. Nga,A. R. Chang,T.-M. Ismail,S.-S. Omar,A. Charlton,M. Salto-Tellez
Cytopathology. 2009; 20(5): 297
[Pubmed] | [DOI]
8 CytoJournalæs move to the new platform: More on financial model to the support open-access charter in cytopathology, publication quality indicators, and other issues
Shidham, VB and Pitman, MB and DeMay, RM and Atkinson, BF
CytoJournal. 2008; 5(1): 15
9 The relevance of molecular diagnostics in the practice of surgical pathology
Siok-Bian, N. and Lee, V. and Das, K. and Salto-Tellez, M.
Expert Opin. Med. Diagn.. 2008; 2(12): 1401-1414


Previous article Next article


  Site Map | Copyright and Disclaimer
© 2007 - CytoJournal | A journal by Cytopathology Foundation Inc with Wolters Kluwer - Medknow
New version online since 1st July '08
Open Access