A COMPARATIVE STUDY OF VAGINAL SMEARS AND CERVICAL
CELL SCRAPINGS IN I N T R A E P I T H E L I A L CARCINOMAS*
D. D. KULCSAR, M.D.
From the Cytological Laboratories, McGill University, Montreal, Canada
Successful treatment of carcinoma of the cervix depends upon the ability to
recognize it in its earliest stages. The diagnosis should be established before
appreciable clinical signs appear since the clinical disease occupies a relatively
short period in the total life cycle of a carcinoma.11 Cytologic examination of
vaginal and cervical smears offers one means of accomplishing this purpose. Because of the amount of work required to screen a large female population, there
has been considerable debate concerning the best method of approach to this
problem.
It is the purpose of this study to determine the comparative value of cytologic
screening by the vaginal pool aspiration method of Papanicolaou13 and the
cervical "surface-biopsy" method developed by Ayre.1 The latter method was
selected for routine use in our laboratory over four years ago because it was
believed that it had the following advantages over the Papanicolaou procedure:
The scraping is made over the squamo-columnar junction which is believed to
be the site of origin of the great majority of cervical cancers; the cells are obtained
in a fresh or relatively well preserved state, offering clear staining-qualities
and a large number of mucosal cells for study. By comparison, the vaginal-pool
method offers fewer cells because of dilution of the material by secretions and
exudates; the cells will usually be dead or in process of degeneration, and they
will not take stains as well nor will the stained cells show the same multicolored
brilliant picture.
Most of the publications dealing with the results of cytologic examinations
have been concerned with the establishment of the accuracy of the method. The
accuracy of the vaginal-pool method is expected to be high in the presence of
cancer involving a large part of the cervix, but it cannot be expected to be as
accurate in the presence of the early stages of cancer, such as is revealed by the
microscopic lesion of intra-epithelial carcinoma. Exfoliation seems limited in
many of these cases, so that fewer neoplastic cells accumulate in the vaginal pool.
There is accumulating evidence8 •16 that intra-epithelial carcinoma is preceded
by hyperactivity and anaplasia of the basal layers of epithelium. Such a stage
perhaps represents a precancerous phase. In manj' lesions of this type the abnormal cells may only be present in a smear when the surface epithelium is
actually scraped away.
MATERIAL AND METHODS
The cytologic classification used is shown in Table 1 which is part of a printed
chart accompanying each slide. The 24 patients selected for this investigation
* Received for publication, May 5, 1950.
958
959
SCRAPINGS OP CERVIX IN CARCINOMA
had been attending the Cytological Laboratory for observation and study. All
of the patients had had several positive smears. Their lesions were classified
as Grade I I / B (pie-cancer) and Grade III/A (pre-invasive cancer), as shown
in the table. These correspond approximately to a stage of intra-epithelial
carcinoma which in some cases will be found only on serial "ring-biopsy". 6
Twenty of these cases had a positive biopsy while the other 4 had as yet no
biopsy but continued to show positive smears.
Smears were taken at weekly to monthly intervals and at each examination
one vaginal smear was obtained according to the Papanicolaou method, and one
cervical smear according to the Ayre method. The patients were told not to
TABLE 1 •
R E P O R T F O R M U S E D R O U T I N E L Y IN THE CYTOLOGICAL LABORATORY
G R A D E S OF CELLULAR ABNORMALITY
Grade 0:
Normal colls
No cancer cells seen
Grade I :
Inflammatory
Hyperactive
cell types
Hyperplasia
dencies
with
precancerous
ten-
Minimal
Grade 11: Anaplastic cells of "precancer cell-complex" *
Grade I I I : Positive cells of fully developed cancer type
Epidermoid carcinoma
mature
undifferentiated
Adenocarcinoma
Indicative of
"nearo-carcinoma",
a cytologic stage
of cancer 5
M a y observe
A
Maximal
May consider
surgery
B
Cells of preinvasive type
A
Malignancy suspected b u t diagnosis inconclusive without biopsy
B
Conclusive evidence of malignancy
C
take a douche for 24 hours prior to the examination. It should be noted that the
douche offered no disadvantage in obtaining the cervical surface-smear but it
was objectionable in obtaining material for a vaginal-pool smear. Patients receiving medication which might have affected the cellular content of the cervical
or vaginal secretions (i.e., estrogenic compounds) were excluded from the study.
The number of slides varied from 2 to 8 pairs per patient and a total of 100
vaginal and 100 cervical smears served as the basis for this study. The smears
were stained by the Papanicolaou polychrome stain. The slides were studied
systematically with a binocular microscope using No. 15 eyepieces.
We considered that a comparison of the results of the study of these smears
960
KULCSAR
should not only reveal the number of positive or negative smears but should also
afford some clue to the ease or difficulty of establishing the diagnosis. Therefore, we decided we would grade the ease of establishing the diagnosis on the
basis of the number of atypical cells or cell groups observed in a smear. We
classified as Group I, smears showing from 1 to 3 atypical cells or groups of cells;
as Group II, those showing from 4 to 8; as Group III, those with 9 to 15; and as
Group IV, those showing more than 15 atypical cells or groups of cells. The cells
or groups of cells were not necessarily in different fields.
RESULTS
Table 2 shows that 93 per cent of the slides of cervical scrapings were positive
for neoplastic cells as against 55 per cent positive of the vaginal smears. It
should be emphasized here that for the purpose of this compai'ative study a
TABLE 2
COMPARATIVE R E S U L T S I N 100
C O N C U R R E N T V A G I N A L P O O L AND C E R V I C A L SURFACE
SMEARS I N I N T R A - E F I T H E L I A L CARCINOMAS
TYPE OF SMEAR
Vaginal pool
Cervical scraping
TOTAL
POSITIVE
NEGATIVE
100
100
55
93
45
7
TABLE 3
VAGINAL SMEARS AND C E R V I C A L C E L L - S C R A P I N G S I N I N T R A - E P I T H E L I A L CARCINOMAS
G R O U P E D ACCORDING TO T H E N U M B E R OK N E O P L A S T I C C E L L S OR G R O U P S O F
CELLS PRESENT
POSITIVE
SMEAR TYPE
TOTAL
NEGATIVE
Group I
Vaginal pool
Cervical scraping.
100
100
45
7
45
19
Group II Group III Group I
5
24
2
24
3
20
single slide representative of each method was used in each case. In our ordinary
routine, every diagnostic test utilized two smears procured from two cervical
scrapings.
Table 3 gives some indication of the ease of detection by showing the number
of neoplastic cells or groups of cells present on the slides. Here we find that a
positive diagnosis was made in 45 per cent of cases with the vaginal smear,
when only a few anaplastic cells were present (Group I). This relative paucity
of cells occurred in only 19 per cent of cases in which a positive diagnosis was
made by the cervical smear method. While it is possible to make a positive diagnosis on the basis of one or two characteristic atypical cells,9 the average cytologist would probably request that another smear be submitted for confirmation.
I t is also very much more exacting and tiring to examine a slide where one can
expect only a few atypical cells. Seventy-four per cent of the cervical smears
showed 4 or more anaplastic cells or groups of cells per smear while only 10 per
SCRAPINGS OF CERVIX IN CARCINOMA
961
cent of the vaginal smears showed this many anaplastic cells. In 26 per cent,
more than 15 anaplastic cells were present and one could make a diagnosis after
a rapid examination of the cervical smear, but this situation was usually present
in only 3 per cent of the vaginal smears.
DISCUSSION
Several publications are concerned with the relative value of the cervical
and vaginal smears. Foote and Li7 studied the smears from 18 cases of intraepithelial carcinoma proved by biopsy; in 14 (78 per cent) they recognized neoplastic cells in the cervical smear but found them in only 9 (50 per cent) of
the smears from the vaginal vault. Posey and Cunningham14 warned that the
small surface area and the slow growth of the intra-epithelial cancers would
permit less desquamation of tumor cells. There would consequently be a larger
error with the vaginal smear. Diddle and his associates,6 using the cervical smear,
found almost as many intra-epithelial carcinomas in 20 months as in the previous
ten years. Skapier,16 who reported his findings in 8000 asymptomatic women,
stated that for optimum results vaginal aspiration alone was not the best procedure to follow.
Younge, Hertig and Armstrong16 found that only 61 per cent of 31 proved cases
with intra-epithelial carcinoma gave positive results with the first vaginal
smear. When they classified their cases, separating those with glandular or
early stromal involvement from those with only surface involvement, they found
that in the latter group 53 per cent were positive on the first or second smear.
Isbell and his associates9 compared the findings by the vaginal smear and tissue
diagnosis in 1045 persons who had operations and found that in 13 with carcinoma
in situ, 5 (38 per cent) had negative smears. In another 13 individuals with
possible or probable carcinoma in situ, 9 (69 per cent) were reported as negative.
The reports cited correspond very well to our experience which shows that almost
50 per cent of the earliest stages of carcinoma of the cervix may be missed by
the use of the vaginal-pool smear technic.
• It appeal's to us that the smear from the cervical surface offers definite advantages over the smear from the vaginal pool. In the former method it takes
considerably less time to screen the slides, and in the great majority of positive
slides, a comparatively larger number of atypical cells will be present. This
enables one to train technicians to screen the slides; it is less likely that smears
containing a larger number of abnormal cells will be missed. There will be less
need for repeating preparations of smears because of so-called "inadequate",
"suspicious", or "doubtful" material. How abundant these may be is evident
from the report of Kraushaar and his co-workers.10
The high degree of accuracy of the "surface-biopsy" scraping method is well
shown by the data in this paper as well as by other publications from our laboratory. 2 - 4 - 12
SUMMARY
1. One hundred smears each of vaginal pool material and of cervical surface
scrapings, taken concurrently from a total of 24 patients with intra-epithelial
962
KULCSAR
carcinoma, were examined and the findings compared. Only a single slide of eacli
type was-obtained at each examination.
2. Neoplastic cells were not found in 45 per cent of the vaginal smears and
in 7 per cent of the cervical smears. Another 45 per cent of the vaginal smears
and only 19 per cent of the cervical smears reported as positive showed 3 or less
atypical cells or groups of cells. Only 10 per cent of the vaginal smears contained
more than 4 atypical cells or groups of cells in contrast to 74 per cent of the
cervical smears.
3. The smear of cervical surface scrapings appears to give a better chance of
discovering the earl}' stages of carcinoma in this region.
Acknowledgment. T h e author wishes t o express his sincere "appreciation t o D r . J . Ernest
Ayre, Director of t h e Cytological Laboratories, for suggesting this study and for his cons t a n t cooperation and help in carrying i t out.
REFERENCES
1. A Y R E , J . E . : Selective cytologv smear for diagnosis of cancer. Am. J . Obst. and G y n e c ,
53: 609-617, 1947.
2. A Y R E , J . E . : T h e diagnosis by vaginal smear. Twelfth British Congress of Obst. and
G y n e c , London, England, July 7, 1949.
3. A Y B E , J . E . : T h e vaginal smear; " p r e c a n c e r " cell studies using a modified technique.
Am. J . Obst. and G y n e c , 58: 1205-1219, 1949.
4. A Y B E , J . E . : Pregnancy following cervix cancer. Surg., Gynec. and Obst., 90: 29S-304,
1950.
5. A Y B E , J . E . , AND A Y B E , W. B . : Progression from "precancer" stage to early carcinoma
of cervix within one year. Am. J . Clin. P a t h . , 19: 770-77S, 1949.
C. D I D D L E , A. W., A S H W O R T H , C. T . , B R O W N , W. W., J R . , AND BRONSTAD, M . T . , J R . :
Noninvasive cervical carcinoma. Am. J . Obst. and Gynec., 57: 376-3S0, 1949.
7. F O O T E , F . W., AND L i , K . : Smear diagnosis of in situ carcinoma of t h e cervix. Am. J .
Obst. and G y n e c , 56: 335-339, 194S.
8. GALVIN, G. A., AND T E L I N D E , R . W . : T h e present-day s t a t u s of noninvasive cervical
carcinoma. Am. J. Obst. and Gynec., 57:15-36, 1949.
9. I S B B L L , N . P . , J E W E T T , J . F . , A L L A N , M . S., AND H E R T I G , A. T . : A correlation between
vaginal smear and tissue diagnosis in 1045 operated gvnecologic cases. Am. J . Obst.
and G y n e c , 54: 576-5S3, 1947.
10. KRAUSIIAAR, O. F . , BBADBURY, J . T . , AND B R O W N , W. E . : T h e vaginal smear in popula-
tion screening for uterine carcinoma. Am. J . Obst. and G y n e c , 58: 447-456, 1949.
11. M E N G E R T , W. F . : Discussion of Galvin and TeLinde's paper: T h e present-day s t a t u s of
non-invasive cervical carcinoma. Am. J . Obst. and G y n e c , 57: 36, 1949.
12. OXORN, H . : Cervical cvtology; key t o diagnosis of earlv uterine cancer. Surg., G y n e c
and Obst., 87:197-205, 194S.
13. PAPANICOLAOU, G. N . , AND T R A U T , H . F . : Diagnosis of Uterine Cancer by the Vaginal
Smear. New York: Commonwealth F u n d , 1943, p p . 3-5.
14. P O S E Y , L . C , AND CUNNINGHAM, J . A . : Impressions of the vaginal smear technic in t h e
diagnosis of cervical cancer. South. M . J., 41: 221-226, 194S.
15. SKATIER, J . : Evaluation of t h e cytologic test in t h e early diagnosis of cancer. Am. J .
Obst. and G y n e c , 58: 366-375, 1949.
16. Y O U N G E , P . A., H E R T I G , A. T . , AND ARMSTRONG, D . : A s t u d y of 135 cases of carcinoma
in situ of t h e cervix a t t h e Free Hospital for Women. Am. J . Obst. and G y n e c , 58:
867-895, 1949.