Silent High Grade Cervical Intraepithelial Neoplasia in Atypical Smears from Liquid Based Cervical Cytology - Three Years Experience in Thammasat University Hospital

Purpose: To study the prevalence of CIN2 diagnosis in women with atypical Papaniculoau (Pap) smears to suggest appropriate management option for Thai health care. Materials and Methods: Data from all patients with liquid based cytology with human papillomavirus (HPV) testing between May 2013 - May 2016 were collected from medical records. Women with atypical cervical Pap smears were recruited. Results for age, HPV testing, HPV 16, 18, 45 and other genotypes tested, colposcopic examination and histopathological assessment were all collected. Atypical smears were defined as atypical squamous cells of undetermined significance (ASC-US) and atypical squamous cells cannot be exclude high grade squamous intraepithelial lesion (ASC-H). Results: A total of 2,144 cases were recruited. Twenty six women with ASC-US on cytology had high risk (HR) HPV detection while eight cases with ASC-H had HR-HPV (40.0% VS 72.7%, p0.005). Among the 26 women with ASC-US cytology and positive HR-HPV, HPV type 16 (n8, 30.8%), type 18 (n1, 3.8%), type 45 (n1, 3.8%) and other HPV types (n17, 65.4%) were found. Eight women with ASC-H and positive HR-HPV demonstrated type 16 (n6, 75%) and other HPV types (n2, 25%). Fifty seven women with ASC-US had normal colposcopy, CIN1 and CIN2 at percentages of 80.7 (46/57), 14.0 (8/57) and 5.3 (3/57), respectively. In the ASC-H group, 7 out of 10 women had normal colposcopy and three (30%) had CIN2 results. Conclusions: In women with ASC-US cytology, immediate colposcopy is highly recommended. HPV testing can be performed if colposcopy is not an available option because there was high prevalence (5.3%) of CIN2 in our findings. ASCCP recommendations for ASC-H that colposcopy should be performed on all ASC-H cases regardless of HPV result are thereby supported by the findings of this investigation.     

液基细胞学与HPV分型联合检测对早期宫颈癌的筛查意义

目的探讨液基细胞学(TCT)联合人乳头瘤病毒(HPV)分型检测对早期宫颈癌筛查的临床意义。方法选择慢性宫颈炎患者714例。TCT采用离心甩片法,HPV-DNA检测采用PCR-反向点杂交法,对TCT和HPV-DNA任一检测阳性或二者均阳性者进行阴道镜取活检检查。结果在HPV感染的各年龄组中,20~30岁组和51~60岁组的感染率较高,分别为36.7%和39.7%,各年龄组感染率差异有统计学意义(χ~2=14.974,P=0.039)。TCT检测的阳性率为25.8%,HPV-DNA检测的阳性率为29.7%,略高于TCT检测,但差异无统计学意义(P<0.05)。HPV-DNA高危型感染者中病理诊断为宫颈癌5例,占6.5%,高于HPV-DNA低危型感染者宫颈癌的发生率(0.7%),差异有统计学意义(P<0.05)。TCT联合HPV-DNA分型检测诊断宫颈癌的敏感度高于TCT和HPV-DNA单独检测,特异度高于HPV-DNA单独检测,假阳性率低于HPV-DNA单独检测,假阴性率低于TCT和HPV-DNA单独检测,差异有统计学意义(P<0.05)。结论TCT联合HPV-DNA分型检测可以提高诊断宫颈癌的敏感性和特异性,对宫颈癌的早发现、早治疗有重要临床意义。     

Clinical Factors Associated with Specimen Adequacy for Conventional Cervical Cytology in Thammasat University Hospital,Thailand

Purpose: To study clinical factors related to adequacy of transformation zone (TZ) components in cervical smears. Materials and Methods: Medical and Papanicolaou (Pap) smear reports from Thammasat University Hospital, Thailand during January to December 2015 were collected. Demographic data was reviewed by attending physicians and impact of clinical factors onTZ adequacy was primary outcome. A total of 3,251 smears were reviewed. Finally, 2,098 smears met The inclusion criteria and enrolled into this study. Results: Average age and bodyweight of participants in this study were 43.0 years and 60.0 kg, respectively. Ninety seven percent of smears were classified as satisfactory for evaluation according to the Bethesda system 2001. Adequacy (group A) and inadequacy (group B) of TZ were equal in percentage (50.9/46.0). Prevalence of abnormal cervical cytology was 4.4%. Percentages of abnormal Pap smears in group A and B were 7.3 and 1.4, respectively (p<0.001). Factors associated with increased adequacy of TZ were old-age ( 50 yr), nulliparity, within 3-months postpartum, history of TZ inadequacy and abnormal smears. Sexually transmitted disease (STD), hormonal usage, previous cryotherapy and smears collected by staff were associated with inadequacy of TZ. Conclusions: Collection of cervical specimens should be carefully performed. STD history, hormonal usage and previous cryotherapy are risk factors for TZ inadequate specimens.     

Anxiety and Depression in Thai Women with Abnormal Cervical Cytology who Attended Colposcopic Unit in Thammasat University Hospital

Background: Colposcopy is the standard investigation for women with abnormal cervical cytology. Waiting timeto colposcopy could impact to psychological distress. Data about anxiety and depression in eastern countries patientswere limited. Aim of this investigation was to evaluate anxiety and depression status in Thai women who were waitingfor colposcopy compared to women who attended gynecology clinic for cervical cancer screening. Materials andmethods: This study was conducted at the outpatient gynecology clinic of Thammasat University Hospital betweenJanuary 2017 to March 2018. A Total of 200 women were recruited into the study. The cases were divided into the studyand control group. Study group consisted of one hundred women with abnormal cervical cytology referred to colposcopy.One hundred of women who attended gynecology clinic for cervical cancer screening was classified as control group.The Hospital Anxiety and Depression Scale (HADS) was used to determine anxiety in the participants. Results: Totalof 200 women who met criteria of the study were recruited. The mean ages of both groups were 40 years old. Bothgroups were significantly different when it came to their education, 30 and 59 percent of study and control group hadeducation level more than bachelor (p=0.003). The prevalence of anxiety was statistically significantly higher in studygroup than the control group (15% and 6%, respectively). There was only one case of depression in study. Waiting timeand abnormal cervical cytology severity did not affected to anxiety level. Conclusions: Colposcopy and appointmentcaused anxiety. However anxiety was not associated with waiting time to colposcopy or Pap result’s severity.     

Cervical Cancer Detection between Conventional and Liquid Based Cervical Cytology: a 6-Year Experience in Northern Bangkok Thailand

Objectives: To determine the prevalence of abnormal Papanicolaou (Pap) smear, cervical intraepithelial neoplasia(CIN) 2 or higher and cancer between conventional Pap smear (CPP) and liquid based Pap smear (LBP). Methods: Thisretrospective study was conducted at Bhumibol Adulyadej Hospital, Bangkok, Thailand between January 2011 andDecember 2016. Data was collected from medical records of participants who attended for cervical cancer screening test.Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy for detectingCIN 2 or higher were evaluated by using the most severity of histopathology reports. Results: A total of 28,564 caseswere recruited. Prevalence of abnormal Pap smear from CPP and LBP were 4.8 % (1,092/22,552) and 5.7 % (345/6,012),respectively. Percentage of unsatisfactory smears in CPP (52.3%) was higher than LBP (40.5%). From CPP and LBP,cervical cancer percentages were 0.2 and 0.1, respectively. Sensitivity, specificity, PPV, NPV and accuracy of CPP andLBP for detection cancer were 42.5 vs 26.1%, 99.9 vs 100.0%, 69.8vs 75.0%, 99.7 vs 100.0 % and 99.7 vs 99.7%,respectively. Conclusion: Prevalence of abnormal cervical cytology and cancer from CPP and LBP were 4.8/0.2and 5.7/0.1 percent, respectively. Unsatisfactory smear of LBP was less than CPP. Sensitivity, specificity, PPV, NPVand accuracy of CPP and LBP for detection CIN 2 or higher and cancer were comparable.     

Population-based Cervical Cancer Screening Using Highrisk HPV DNA Test and Liquid-based Cytology in Northern Thailand

Background: Northern Thailand is a region with a high cervical cancer incidence. Combined high-risk HPV (hrHPV) DNA testing and cytology (co-testing) has increasingly gained acceptance for cervical cancer screening. However, to our knowledge, data from a population-based screening using co-testing have not been available in this region. This study therefore aimed to evaluate the performance of cytology and hrHPV test in women in northern Thailand. Materials and Methods: Cervical samples were collected for hybrid capture 2 (HC2) testingand liquid-based cytology from women aged 30 to 60 years who were residents in 3 prefectures of Chiang Mai in northern Thailand between May and September 2011. Women with positive cytology were referred to colposcopy, while women with positive for HC2 only were followed for 2 years. Results: Of 2,752 women included in this study, 3.0% were positive in both tests, 4.1% for HC2 only, and 1.3% had positive cytology only. At baseline screening, positive HC2 was observed in 70.6% among cytology-positive women compared with 4.3% amongcytology-negative women. The prevalence of positive HC2 or cytology peaked in the age group 35-39 years and was lowest in the age group 55-60 years. High-grade squamous intraepithelial lesion or worse lesions (HSIL+) were histologically detected in 23.5% of women with positive baseline cytology and in 9.8% of women with positive baseline HC2 only on follow-up. All women with histologic HSIL+ had positive baseline HC2. Conclusions: The hrHPV test is superior to cytology in the early detection of high-grade cervical epithelial lesions. In this study, the prevalence of histologic HSIL+ on follow-up of women with positive hrHPV test was rather high, and these women should be kept under careful surveillance. In northern Thailand, hrHPV testing has a potential to beused as a primary screening test for cervical cancer with cytology applied as a triage test.     

Manual Liquid Based Cytology in Primary Screening for Cervical Cancer - a Cost Effective Preposition for Scarce Resource Settings

Conventional pap smear (CPS) examination has been the mainstay for early detection of cervical cancer.However, its widespread use has not been possible due to the inherent limitations, like presence of obscuring bloodand inflammation, reducing its sensitivity considerably. Automated methods in use in developed countries maynot be affordable in the developing countries due to paucity of resources. On the other hand, manual liquid basedcytology (MLBC) is a technique that is cost effective and improves detection of precursor lesions and specimenadequacy. Therefore the aim of the study was to compare the utility of MLBC with that of CPS in cervical cancerscreening. A prospective study of 100 cases through MLBC and CPS was conducted from October 2009 to July2010, in a Medical College in India, by two independent pathologists and correlated with histopathology (22cases). Morphological features as seen through MLBC and CPS were compared. Subsequently, all the cases weregrouped based on cytological diagnosis according to two methods into 10 groups and a subjective comparison wasmade. In order to compare the validity of MLBC with CPS in case of major diagnoses, sensitivity and specificityof the two methods were estimated considering histological examination as the gold standard. Increased detectionrate with MLBC was 150%. The concordance rate by LBC/histopathology v/s CPS/histopathology was alsoimproved (86% vs 77%) The percentage agreement by the two methods was 68%. MLBC was more sensitive indiagnosis of LSIL and more specific in the diagnosis of inflammation. Thus, MLBC was found to be better thanCPS in diagnosis of precursor lesions. It provided better morphology with increased detection of abnormalitiesand preservation of specimen for cell block and ancillary studies like immunocytochemistry and HPV detection.Therefore, it can be used as alternative strategy for cervical cancer prevention in limited resource settings     

Flow Cytometric Analysis of DNA Ploidy in Liquid Based Cytology for Cervical Pre-Cancer and Cancer

Background: DNA ploidy analysis of cervical intraepithelial neoplasia (CIN) and invasive cervical cancer samples by flow cytometry (FCM) has been established as an aid to prognostic assessment. Liquid based cytology (LBC) increases diagnostic specificity by using ancillary techniques that provide information beyond morphology. The present study was undertaken to assess DNA ploidy in LBC samples as an adjunct for early detection of cervical pre-cancer and cancer. Methods: DNA ploidy assessment was performed on LBC samples of 50 cases and 31 controls. Cell pellets were obtained by centrifugation and stained with Telford reagent. At least 20,000 R1 gate (G0-G1) events were acquired on a BD FACSCalibur by using a 575±10 nm filter. Results: Mean diploid G1 values were lowered significantly (p<0.01) while diploid S values were significantly elevated (p<0.01) in both high grade squamous intraepithelial lesions (HSILs) and squamous cell carcinomas (SCCs) as compared to controls. Receiver operating curve (ROC) analysis of the diploid G1 value was found to have significant diagnostic potential (AUC=0.682, Z=2.00, p=0.046) for distinction between control and low grade squamous intraepithelial lesion (LSIL) at a cut off value of ≤91.6 with a sensitivity and specificity of 50.0 and 87.1%, respectively. Conclusions: ROC analysis of diploid G1 and diploid S values allows discrimination between LSIL and HSIL with sensitivities and specificities of 65 and 100% and 70 and100%, respectively, and between LSIL and SCC cases with values of 71.4 and 100% and 64.3 and 100%, respectively.     

A Model Approach for Assessing the Benefits of HPV Testing against Cytology in Screening for Cervical Cancer Precursors in Thailand

Objective: The aim of this study was to compare the efficacy of HPV 16/18 genotyping test, high risk HPV DNA testing, alone and in conjunction with the liquid-based cytology method in screening for cervical cancer precursors. Methods: A Markov model was used to describe the course of the cases of CIN2+ that had been detected over a 35 year period. Screening programs started at age 30 and were performed at an interval of once every five years. The model compared three strategies of HPV 16/18 genotyping with reflex cytology triage, high-risk HPV testing alone with referral to colposcopy and cytology-based screening with referral to colposcopy. We assumed the rate of patients lost to follow-up for those referred to colposcopy would be 0%. The clinical parameters were estimated using the data from a study conducted by the Thailand National Cancer Institute. Result: Of the three screening strategies evaluated, the high risk HPV DNA testing alone was the most effective for detecting CIN2+ over the 35 year study period. It detected 143 and 510 cases per 100,000 women more than the HPV 16/18 genotyping test and cytology-based strategy, respectively. The HPV genotyping test detected 368 cases per 100,000 women more than the cytology-based approach. In addition, when viewed with five year intervals, there were missed cases totaling approximately half of the detected cases screened by the cytology strategy and 10% of cases detected with screening by the HPV genotyping test. Conclusion: This study strongly indicates that HPV/DNA testing is preferable to cytology-based screening for cervical cancer precursors. However, the balance between the benefits, burdens and cost of each screening program should be considered.     

Prevalence of Abnormal Cervical Cytology in HIVNegative Women Participating in a Cervical Cancer Screening Program in Calmette Hospital,Cambodia

Prevalence of Abnormal Cervical Cytology in HIVNegative Women Participating in a Cervical Cancer Screening Program in Calmette Hospital, Cambodia     

HC2-HPV 检测法联合液基细胞学在宫颈癌及癌前病变筛查中的临床意义

目的：探讨HC2-HPV检测法联合液基细胞学在筛查宫颈癌及癌前病变中的意义。方法应用HC2-HPV检测法联合液基细胞学技术对体检的患者进行免费宫颈癌及癌前病变的筛查。对不典型增生患者或（和） HC2-HPV检测阳性的患者行阴道镜下宫颈活检。结果液基细胞学检查对宫颈高度病变的检出率为11．0％（11／100）;HC2-HPV检测对宫颈高度病变的检出率为27．2％（22／81）,对宫颈癌的检出率高达100．0％。 HC2-HPV检测法联合液基细胞学检测阳性与病理检查阳性符合率为64．2％（52／81）,显著优于TCT（52．0％）单独检查时的阳性符合率（P＜0．05,χ2＝11．39）。结论 HC2-HPV检测法联合液基细胞学检测对宫颈癌及癌前病变的筛查具有重要的临床推广价值。     

Chlamydia Trachomatis Infection in High-Risk Human Papillomavirus Based on Cervical Cytology Specimen

Objective: High-risk human papillomavirus (HR HPV) was associated with the development of cervical cancer. Asymptomatic Chlamydia trachomatis (C. trachomatis) infection is the most common bacterial, sexually-transmitted infection. This study aimed to investigate the association of C. trachomatis in positive HR HPV and the cytological results from liquid-based cytology (LBC). Methods: 150 residual LBC specimens were collected; all of which had undergone cytology and HPV testing by Cobas. The samples were established as C. trachomatis using real-time PCR (RT-PCR) with Cryptic F/Cryptic R primers. Results: Of 150 positive HPV findings, the most common (72.7%, 109/150) were the 12 other HR HPVs (viz., 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68). The cervical cytology of those positive HR HPVs were mostly negative (70.0%, 105/150).  The C. trachomatis infections in positive HR HPV were 16% (24/150) HPV. The analysis of the abnormal cytology revealed that 41.6% had C. trachomatis co-infection (C. trachomatis and HPV infection) viz., LSIL (20.8%), HSIL (12.5%), and ASC-US (8.3%). A comparison with positive HPV without C. trachomatis co-infection revealed that the highest prevalence was for LSIL, ASC-US, and HSIL (11.1%, 10.3%, and 6.4%, respectively). There was no difference between the abnormalities and negative cervical cytology with negative and positive C. trachomatis co-infection in HR HPV positive (p = 0.174). Conclusion: C. trachomatis infection was not significantly associated HR-HPV and abnormal cytology. This study confirms the increasing rate of C. trachomatis infection in asymptomatic women so routine screening for these infections has been suggested to (a) prevent complications such as the chronic pelvic pain associated with prolong infection and (b) reduce sexual transmission of the infection.     

高危型HPV检测在宫颈癌筛查中的临床研究进展

宫颈癌的发生率仍高居女性生殖系统恶性肿瘤的首位。近年来的研究表明,宫颈癌和高危险型人乳头状瘤病毒（high—risk human papill—omavirus,HR-HPV）之间存在着明确的相互联系,HPV感染是宫颈癌的主要病因。同时许多可靠证据表明在宫颈上皮内瘤变（CIN）、尤其是CIN2、3的筛查中,HPV检测比宫颈细胞学检查具有更高的敏感性。     

FHIT、C-myc在宫颈癌中的表达及其与高危型HPV感染的相关性

[目的]探讨脆性组氨酸三联体(fragile histidine traid,FHIT)、C-myc在宫颈癌中的表达及与高危型人乳头状瘤病毒(high-risk HPV,HR-HPV)感染的相关性.[方法]采用免疫组化SP法检测50例宫颈癌组织(cervical cancer)、70例宫颈上皮内瘤变(CIN)和30例正常宫颈组织中FHIT和C-myc的表达情况,并分析其与宫颈癌临床病理特征的关系.采用HC-Ⅱ法检测HR-HPV感染情况.[结果](1)正常宫颈组织、CIN组及宫颈癌组中FHIT的阳性表达率分别为93.3％、67.1％、22.0％(P＜0.05),C-myc的阳性表达率分别为16.7％、47.1％、76.0％(P＜0.05).(2)FHIT表达与FIGO分期、病理学分级相关(P＜0.05),C-myc表达与FIGO分期相关(P＜0.05).(3)HR-HPV在正常宫颈组织、CIN组及宫颈癌组中的感染率分别为3.33％、28.57％、84.0％.FHIT与C-myc的表达呈负相关(r=-0.622,P＜0.05),FHIT表达与HR-HPV感染呈负相关,C-myc表达与HR-HPV感染呈正相关.[结论]联合检测FHIT、C-myc表达以及HR-HPV感染情况,可能可为早期宫颈癌诊断提供参考依据.     

肉眼观察法联合电子阴道镜检查在宫颈癌筛查中的应用

[目的]对新疆维吾尔族妇女肉眼观察宫颈（VIA,VILI）法联合电子阴道镜检查进行宫颈癌筛查,评价其对宫颈癌及癌前病变的应用价值。[方法]对新疆和田29～60岁的2005名维吾尔族农村妇女进行宫颈癌筛查。采取VIA、VILI法,对VIA、VILI异常者结合电子阴道镜检查,在异常阴道镜图象区取宫颈活检,病理诊断为金标准。[结果]2005名农村妇女中VIA阳性41例,占2.04%（41/2005）,其灵敏度、特异度、阳性预测值、阴性预测值分别为65.63%、98.98%、51.22%、99.44%;VILI阳性49例,占2.49%（49/1964）,其灵敏度、特异度、阳性预测值、阴性预测值分别为53.57%、98.24%、30.61%、99.32%;阴道镜转诊90例,占4.49%（90/2005）;宫颈活检65例,病理诊断为炎症33例、CIN24例、宫颈癌8例。[结论]在宫颈癌筛查中采用VIA、VILI法具有一定的阴性预测价值;结合阴道镜检查能够初步判断病变的程度,确保活检部位的准确性。     

Acceptability of Self-Sampling HPV Testing Among Thai Women for Cervical Cancer Screening

Background: Acceptability of self-sampling HPV testing is confirmed worldwide. However, some cultural differences may affect this question. Therefore, this study was conducted to evaluate the acceptability of selfsampling HPV testing in Thai women. Materials and Methods: One hundred women aged 30-65 years with anintact cervix were included in this study. The participants were asked to do the Pap test by physicians and then brush type self-sampling instruments were assigned for self-collection and finally completed a questionnaire for acceptability evaluation. The questionnaire contains 2 parts. Part one covered general information of the participants and part two is the acceptability questions. Results: Mean age was 40.6 years. The incidence of high risk HPV detection in this study was 16%. The most common reason for doing Pap smear was for annualcheckup. On the topic of ease of use, 85 % of the subjects agreed. Most of the participants (82%) reported that they felt less pain. However, reliability of the result was not satisfactory because 37% of the participants hesitated to rely on the results of the test. According to the price, if the price is less than 1,000 Baht (32.59 Baht = 1USD), 82% of the subjects would use it for their next screening. Conclusions: The acceptability of self-sampling device in this study is quite good but the reliability of the test was questioned by some of the participants. Moreover, the price of the test in Thailand may also influence the acceptability of the test.     

Mapping HPV Vaccination and Cervical Cancer Screening Practice in the Pacific Region-Strengthening National and Regional Cervical Cancer Prevention

Objective : To provide background information for strengthening cervical cancer prevention in the Pacificby mapping current human papillomavirus (HPV) vaccination and cervical cancer screening practices, as wellas intent and barriers to the introduction and maintenance of national HPV vaccination programmes in theregion. Materials and Methods: A cross-sectional questionnaire-based survey among ministry of health officialsfrom 21 Pacific Island countries and territories (n=21). Results: Cervical cancer prevention was rated as highlyimportant, but implementation of prevention programs were insufficient, with only two of 21 countries andterritories having achieved coverage of cervical cancer screening above 40%. Ten of 21 countries and territorieshad included HPV vaccination in their immunization schedule, but only two countries reported coverage of HPVvaccination above 60% among the targeted population. Key barriers to the introduction and continuation ofHPV vaccination were reported to be: (i) Lack of sustainable financing for HPV vaccine programs; (ii) Lackof visible government endorsement; (iii) Critical public perception of the value and safety of the HPV vaccine;and (iv) Lack of clear guidelines and policies for HPV vaccination. Conclusion: Current practices to preventcervical cancer in the Pacific Region do not match the high burden of disease from cervical cancer. A regionalapproach, including reducing vaccine prices by bulk purchase of vaccine, technical support for implementationof prevention programs, operational research and advocacy could strengthen political momentum for cervicalcancer prevention and avoid risking the lives of many women in the Pacific.     

Incidental Finding of Abnormal Cervical Pathology in Hysterectomy Specimens after Normal Preoperative Papanicolaou Smears in Thammasat University Hospital

Background: To investigate abnormal cervical histopathology (ACH) from hysterectomy specimens withnormal preoperative Papanicolaou (Pap) smears. Materials and Methods: Medical records from May 2009to April 2012 were retrospectively reviewed of subjects from whom hysterectomy specimens were taken inThammasat University Hospital. All had normal preoperative Pap smears. ACH was the primary outcome. Ap-value less than 0.05 was considered significant. A total of 483 subjects with an average age of 50.5 years wererecruited. Benign cases of enlarged uterus and pelvic mass were present in 94% (430/483). Endometrial andovarian cancer were found at 6.2 and 4.7%, respectively. In hysterectomy specimens there were 19 (4%) casesof ACH. Silent ACH with benign disease, endometrial and ovarian cancers were 1.2% (5/430), 33.3% (10/30)and 17.4% (4/23), respectively. The negative predictive value (NPV) and false negative rate of Pap smears were96 and 4%, respectively. ACH in malignant cases were 27.9% (12/43) and 20% (2/10) in adequate (APS) andinadequate (IPS) Pap collection groups, respectively. ACH in benign condition were 0.68% (2/292) and 2.2%(3/138) in APS and IPS, respectively. ACH was more often found in hysterectomy specimens with indication ofmalignancy than benign conditions with statistical significance. One third of preoperative stage I endometrialcancer cases had cervical involvement. Conclusions: Silent ACH in normal preoperative Pap smear was 4%. Inadequate Pap smear collection is still the major problem in this study. Reducing inadequate Pap smearcollection could reduce the false negative rate.