168 Del Pup L et al. / Vaginal cytology in gynecological cancer TABLE 1. Differences in cytologic adequate sampling (optimal and suboptimal) between the two sampling devices: Ayre’s spatula and cytobrush Group A: Group B: Ayre’s spatula Cytobrush (Chi square test, p= 0.008) Optimal Suboptimal n 23 38 65 % 35.9 61.3 n 41 24 61 % 64.1 38.7 Total n 64 62 126 same approach. Smears were immediately fixed by cytofix spray with uniform distribution over the smear without artifacts. Staining was conducted by standard Papanicolau method. One pathologist (CV), blinded to the sampling method, analysed all the samples. The cellularity was considered subop- timal when scanty and/or showing an unsuitable morphology for diagnosis. Criteria of adequacy for vaginal vault cytology consisted in the evalu- ation of adequate cellularity of squamous type. However, since the goal of the work was to estab- lish the best method to collect more vaginal cells for smears, some differences in the amount of cells available for evaluation between the two methods were expected. The Chi-square test for heterogene- ity, OR and their 95% CI were computed to assess statistical associations. Results All samples were accepted as adequate. In the preliminary study, fifteen specimens showed a higher cellularity using cytobrush (Figure 1). In the second part of the study, among patients where the vaginal cytology with Ayres spatula was per- formed, 41 patients had a suboptimal quantity of collected cells and 23 of them an optimal one. Among patients who underwent vaginal cytology with cytobrush, 24 had a suboptimal cytology and 38 an optimal one. This difference was statistically significant (p= 0.008), while the OR for an optimal cytology using the cytobrush was 2.8 (95% C.I. 1.3- 6.2) (Table 1). There were no side effects, such as bleeding, in both sampling groups. Discussion Our data suggested that the cytobrush is a more ef- ficient sampling device than the traditional Ayre’s spatula btain from vaginal vault. Indeed, it allows collecting 2.8 times the amount of optimal speci- men, as it enables more efficient cell scraping from Radiol Oncol 2012; 46(2): 166-169. the vaginal epithelium, which is almost invariably atrophic in hysterectomized gynaecologic cancer patients. The cytobrush device carries also the advantage of a deeper sampling by reaching the narrow corners sometimes produced by surgical interventions in the vaginal vault. In these hidden spaces, an initial recurrence can also be difficult to be visualized or palpated. Furthermore, plastic ma- terials tend to have a lower adherence than wood- en spatulas, allowing more cells to be smeared to the slide for the analysis. The Ayre’s spatula is the device commonly used for cervical cytology and the one used in previous vaginal vault cytology studies that are summarized below. Vaginal vault cytology is gen- erally performed during follow-up, after hyster- ectomy for cervical cancer. Only one patient, out of 79 completing a 15-year follow-up study6, had an abnormal smear and a vaginal intraepithelial neoplasia (VAIN) later diagnosed and no patient developed invasive vaginal carcinoma. A French study7, conducted over a 10-year period on 2152 patients, reported only four cases of invasive can- cer of the vagina of which one occurring after radi- cal hysterectomy for invasive cancer of the cervix and three after total hysterectomy for cervical in- traepithelial neoplasia (CIN). The follow-up of endometrial cancer does not seem to improve the survival. A Canadian study8 concluded that the routine use of vaginal vault smears was not cost ef- fective during the follow-up. A detection of each asymptomatic vaginal recurrence requires 1067 Pap-smear tests, producing benefits for only 0.5% of patients.9 Neither recurrence free nor the overall survival are improved in these cases compared to those detected at clinical presentation.10,11 Only in non-irradiated patients, a strong case can be made for regular follow-up to detect vaginal recurrence at the earliest opportunity, given the high salvage rate following radiotherapy.12,13 In a systematic re- view, the detection of asymptomatic recurrences of endometrial cancer ranged from 0% to 4% with vaginal vault cytology, as compared to 5% to 33% with physical examination.14