Prompted by feedback from the 34th European Congress of Cytology (ECC), the practice of including a special symposium in the programme was continued in the 35th ECC in Lisbon (2009) by arranging a satellite symposium entitled 'Cervical Cancer Screening in the Mediterranean Countries'. Because of the importance to the future of this discipline, it was felt appropriate to summarize the highlights of this symposium here. Cervical cancer prevention strategies in the countries participating in the symposium (Portugal, Spain, Italy, Croatia, Greece and Turkey) appear to be highly variable. As yet, none of these countries can demonstrate a fully implemented national screening programme, but all are in different phases of designing and/or setting up such a programme, which is important. At present, the time-honoured concept of cervical cancer prevention by Pap smear screening is under review, because prophylactic human papillomavirus (HPV) vaccines demonstrate a potential to prevent the vast majority (albeit not all) of cases of cervical cancer in the foreseeable future. Cervical cancer screening is still needed in this emerging era of HPV vaccination, but clearly the existing screening strategies must be modified to provide a cost-effective combination of vaccination and screening. If the currently evaluated new screening strategies, such as HPV testing followed by cytology triage, become a reality, there is the likelihood that the Pap test will have only a secondary role, subordinate to HPV testing. Supporters of this scenario claim that Pap test performance will deteriorate in vaccinated populations. Reduced positive predictive value (PPV), due to lower disease prevalence, is inevitable, however, and this would also affect HPV tests. Any decline in sensitivity and specificity depends on human performance, and as such is avoidable by taking appropriate preventive measures. As clinical cytologists, we should focus attention on minimizing the risk to the Pap test of falling sensitivity because of unfamiliarity with abnormal cells, and also of reduced specificity if the fear of missing significant disease leads to overcalling of benign abnormalities.

The European panel agreed that reproducibility and translatability of terminology in cervical cytology were essential, arguing well for harmonization of reporting systems. The majority at this meeting use a modification of the Bethesda system (BS). Local modifications involved reporting subcategories within high grade and low grade lesions, which would not alter the overall translatability of their systems both with each other and BS. The majority agree that low grade lesions with and without koilocytosis should be managed similarly as should high grade lesions (moderate dysplasia/CIN2 or worse). Those systems linking moderate dysplasia with mild rather than severe dysplasia would need to define moderate dysplasia as such, if their results were to be translatable, which would be preferable to their using a different definition of low grade and high grade lesions. Translation between systems might anyway be facilitated by reporting moderate dysplasia as a subcategory within high grade, which was favoured by most of those present. Therefore, there is no need for exact agreement of terminology if broad principles are agreed. This useful discussion adds weight to the British Society for Clinical Cytology recommendation that the new classification should be adopted by the UK National Health Service Cervical Screening Programme. If the new classification is adopted, the UK would join the European consensus opinion on terminology.

Although larger studies are needed, our data support the predictive value of MN, NPB and NBUD as biomarkers of genomic instability for evaluation of risk level of cancer diseases.

There is still debate on what is the optimal follow-up protocol after a treatment for preinvasive cervical disease. We performed this study in order to improve diagnostic accuracy of the follow-up protocol and at the same time reducing the number of overtreated patients. One hundred and fourteen patients were followed up after conization for CIN3 and/or AIS at 3-6 month, 9-12 month and 18-24 month intervals, then yearly. The follow-up consisted of cytology, colposcopy with biopsy if needed and HPV testing. The end-point of the study was a secondary treatment due to a high suspicion of resdidual/recurrent disease or disease free period of at least 24 months. The median follow-up time was 41 months (5-72 months). In predicting residual/recurrent disease cytology had a specificity of 88.9%, sensitivity of 100%, PPV of 33.3% and a NPV of 100% whereas HPV had a specificity of 76.9%, sensitivity of 100%, PPV of 21.4% and a NPV of 100%. According to our results both tests can be used as a primary follow-up tool after conization. The choice should depend on a socio-economic aspect. In our setting the HPV test should be done only in those patients with a positive smear any time during follow-up as the point of decision for a second treatment. With this approach we could considerably decrease the number of reoperated patients and co-morbidities.