Assessment of Static Telecytological Diagnoses’ Reproducibility in Cervical Smears Prepared by Means of Liquid-Based Cytology Thomas Tsilalis, M.D., 1 Stavros Archondakis, M.D., 1 Christos Meristoudis, M.D., 2 Niki Margari, M.D., Ph.D., 2 Abraham Pouliakis, Ph.D., 2 Lazaros Skagias, M.D., 1 Ioannis Panayiotides, M.D., Ph.D., 3 and Petros Karakitsos, M.D., Ph.D. 2 1 Department of Cytopathology, 401 General Army Hospital, Athens, Greece. Departments of 2 Cytopathology and 3 Histopathology, ‘‘ATTIKON’’ University General Hospital, Athens, Greece. Abstract Objective: This study evaluated the accuracy and reproducibility of telecytological diagnoses proffered on the basis of digitized images from cervical smears prepared by means of liquid-based cytology. Materials and Methods: Representative digital cytological images from a total of 404 cervical smears (benign, 135; atypical squamous cells of undetermined significance, 92; low-grade squamous intra- epithelial lesion, 62; high-grade squamous intraepithelial lesion, 87; squamous cell carcinoma, 26; and adenocarcinoma, 2) were uploaded to the CytoTrainer e-learning telecytology platform (de- veloped in the Department of Cytopathology, ‘‘ATTIKON’’ University General Hospital, Athens, Greece) with specific password-protected accounts and were reviewed remotely by four independent board- certified cytopathologists (checking round). Their reports were recorded and classified. After 12 and 24 months, the same repre- sentative digital images were transferred in random order to the same cytopathologists and were reviewed again (first and second review rounds, respectively). The cytopathologists’ first and second round diagnoses were recorded and compared with their initial ones. Results: Statistical evaluation of cytological diagnoses detected no significant difference in diagnostic accuracy among checking and review diagnoses. The overall interobserver agreement was almost perfect with j values of 0.79–0.97, whereas intraobserver agreement ranged from almost perfect to perfect with j values of 0.76–1 in all diagnostic rounds. Conclusions: Digital images of cervical smears can be used for rapid and accurate diagnosis, by diminishing turn- around times and improving small cytology departments’ quality indices. Diagnoses made by using static telecytological systems can be as reliable as those made by using conventional microscopy, under the conditions that representative images are taken and that stan- dard cytological diagnostic criteria are applied. Telecytology can be used as an alternative method for the cytologic diagnosis of cervical smears, particularly in quality assurance programs. Key words: cervical smear, gynecology, liquid-based cytology, tele- cytology, telepathology, diagnostic reproducibility, interobserver agreement, intraobserver agreement Introduction T elecytology is a component of telemedicine and is simply defined as the practice of transmitting digital cytology images through telecommunication networks to remote viewing locations for diagnosis, storage, or education. 1 It can be used for obtaining expert opinions on difficult cases from distant laboratories, as well as for training and educational pur- poses. 2,3 Telecytological diagnosis can be achieved either with the use of cytological pictures viewed in real time from the microscope (dynamic telecytological systems) or with the use of cytological pictures that are first captured in a digital format and then trans- mitted using a store-and-forward approach to distant observers (static telecytological systems). 4 Few studies have focused on the possible impact of static telecytology in the everyday laboratory’s work flow. Most of these studies have found a high (90–95%) con- cordance between telecytological and glass slide diagnoses. 5–10 Still, there are not enough studies available referring to the method’s diagnostic reproducibility, especially in the field of gyne- cologic cytology. The aim of this study was to confirm static tele- cytological systems’ diagnostic reproducibility by measuring interobserver and intraobserver agreements among four cyto- pathologists who reviewed through an e-learning platform static, digitized, representative images from cervical smears. Materials and Methods The current study was carried out on 404 consecutive cervical smears: benign, 135; atypical squamous cells of undetermined sig- nificance, 92; low-grade squamous intraepithelial lesion, 62; high- grade squamous intraepithelial lesion, 87; squamous cell carcinoma, 26; adenocarcinoma, 2. The material collected was prepared by the ThinPrep 2000 automated slide processor (Cytyc Co. [now Hologic Ò , Bedford, MA]). From each case, one slide was prepared, stained by the Papanicolaou method, and examined by a skilled cytopathologist. Copies of the original cytological reports were kept for further evaluation and comparison with the final histological diagnoses. All cytological slides were retrospectively collected from the de- partment’s registry in sequence and randomly numbered from 1 to 404. One cytopathologist imaged 10 representative fields from each case. Images were captured with a Hamamatsu C4742-95 digital camera (Hamamatsu Photonics, Herrsching am Ammersee, Germany) mounted on a Leica DMLB microscope (Leica Microsystems, Wetzlar, 516 TELEMEDICINE and e-HEALTH SEPTEMBER 2012 DOI: 10.1089/tmj.2011.0167