The compilation of a new cytology nomenclature represents an important, long overdue
step. It is an issue which the cytology societies have been discussing for years.
When he was drawing up the agenda for the S3 Guideline on the Prevention of Cervical
Cancer, the chairman of the S3 Guideline pointed out that an update of the Munich
II Nomenclature was urgently needed, to allow – among other things – the results of
international studies to be adapted to a German context. The study group developing
the new Guideline agreed with this recommendation, incorporated it in its PICO
questions, and requested the members of cytology societies to modernize the cytology
nomenclature as quickly as possible. After P. H. reported about the current state
of affairs at the board meeting of the DGGG [German Society for Gynecology and Obstetrics]
on November 9, 2012, the DGGG also endorsed the recommendation supporting a revision
of the Munich Nomenclature.
When drawing up new morphological nomenclatures it is very important to consult with
and involve as many professional societies and study groups as possible to already
achieve a broad consensus in the early stages after extensive discussion. When the
Bethesda system was being updated, 400 participants from 20 countries attended the
2001 Workshop, which also included internet bulletin boards with 1000 comments about
the new system. We could learn a lot from the Americans; it is the only way in which
potentially “the communication between cytologists, gynecologists, and patients
could improve”, something that was considered advisable in the second conclusion of
Munich III. In the first conclusion, sensitivity is confused with positive predictive
value: a new nomenclature cannot improve the sensitivity of the method if the method
of investigation remains the same. All four conclusions of the Munich III article
remain purely hypothetical but are sold to the reader as proven advantages of the
new nomenclature. This contradicts the basic tenets of evidence-based medicine and
cannot be allowed to stand unchallenged. But both of the letters to the editor do
not address this crucial issue.
The two letters have confirmed us in our opinion that nomenclatures can and should
be discussed. To begin with, we sent our original comment printed in this journal
as a letter to the editor of the journal Der Frauenarzt. However, Der Frauenarzt refused to publish it, in the same way it has refused for years to publish similar
topics and persons, thereby showing a complete disregard for the standard practice
of the scientific community.
We welcome the discerning comments in the letter by W. Kühn et al. about the old category
IIw and IIID and on differentiating a CIN 2 from a CIN 3 (in contrast to the American
approach), as CIN 2 has a different biological significance. We also do not challenge
the inclusion of glandular cell changes in the Munich III Nomenclature, even though
this differentiated subcategorization of glandular cell changes (IIg, IIIg, IIIe,
IVg, Vg, Ve) into probabilities and localizations (following the Bethesda system)
is difficult to do and will doubtlessly require scientific evaluation in
the next few years. By the way, we would like to note that HPV confirmation is the
only method which permits the primary tumor to be allocated to either the cervix or
endometrium in patients who have a diagnosis of “endometrioid adenocarcinoma”.
Colposcopy is indisputably the most important method to investigate abnormal findings;
however, the older the patient, the more common the presence of a type 3 transformation
zone, where colposcopy will not help.
The ASCPC Consensus Guidelines outlining the proper procedure for atypical cytological
and HPV-positive findings are 29 pages long and include 17 algorithms; their complexity
has not been even adequately considered in the clinical recommendations given in Munich
III. Cytologists should therefore in future be guided, when making recommendations,
by the S3 Guidelines which will soon be available and largely forgo the clinical recommendations
of Munich III. The observation in the letter of Griesser et al. that the Munich III
recommendations for investigating abnormal findings are
necessary in order to integrate more meaningful diagnostic methods which will be available
in the foreseeable future is illogical. If it is not yet clear which diagnostic methods
will be used, then it would make more sense to refer to the S3 Guidelines. The guidelines
are transparently compiled at considerable effort and with substantial financial/organizational
support from the German Guideline Program in Oncology (German Cancer Society, German
Cancer Aid, AWMF [Association of the Scientific Medical Societies in Germany]) and
include the views of a representative group of
experts through contributions from different scientific societies with the methodological
support of two internationally renowned specialist institutes for meta-analysis and
GRADE interpretation and are regularly updated to take account of the most recent
scientific data.
In conclusion, we would like to state that the Munich III Nomenclature could potentially
represent an improvement and that it would be useful to measure this. We, too, hope
that it will be widely accepted and implemented, with regular re-evaluations of important
quality parameters which have yet to be defined. Criticism is important for scientific
debate and is conducive to the quest for improvement with all its positive connotations.
