Original Article

Comparison of BD Surepath and

ThinPrep Pap Systems in the
Processing of Mucus-Rich Specimens
Shelly Kenyon, MS, CT1; Brenda J. Sweeney, MS, SCT1; James Happel, BS, DLM, HTL1;
Gloria E. Marchilli, MS, SCT2; Barbara Weinstein, MD2; and Douglas Schneider, MD1

BACKGROUND: Excessive mucus, as well as blood and inflammation, can be problematic in the processing
and screening of liquid-based cervical Pap preparations by interfering in the process of cell retrieval onto
specimen filters or slides. This study compares the capacity of the BD SurePath and ThinPrep liquid-based
Papanicolaou (Pap) tests to handle mucus-laden specimens. METHODS: A 100 lL volume of pooled cervi-
cal epithelial cells was added to BD SurePath and ThinPrep liquid Pap test vials. Aliquots of cervical mucus
that had been collected and pooled from previously processed mucus-rich Pap specimens were added to
each series of test vials in amounts of 250 lL, 500 lL, 1000 lL, and 2000 lL. The vials were then routinely
processed on their respective instruments and the test slides evaluated for cellularity of the squamous cell
component. RESULTS: The BD SurePath test specimens showed no reduction of the squamous cell compo-
nent resulting from the addition of any of the aliquots of mucus. The ThinPrep test specimens showed a
marked loss of cellularity upon the addition of the first aliquot of mucus, with large areas of the filters
showing nearly complete absence of squamous cells. CONCLUSIONS: Excessive mucus remains a poten-
tially limiting factor in the ThinPrep Pap system. This appears to be the result of direct obstruction of the
filtration membrane causing a markedly diminished retrieval of squamous epithelial cells and potentially
impacting disease detection. The BD SurePath system, conversely, manages mucus by a cell enrichment
process, which results in undiminished cell recovery as observed in this study’s test conditions. Cancer
(Cancer Cytopathol) 2010;000:000–000. V C 2010 American Cancer Society.

KEY WORDS: Pap test, liquid-based cytology, BD SurePath, ThinPrep, Papanicolaou smear, mucus,
squamous intraepithelial lesion (SIL).

The Papanicolaou (Pap) test is subject to limitation by obscuring factors that include blood, inflamma-
tory cells, and debris.1,2 Theoretically, this situation applies to liquid-based Pap technologies as well as the
conventional Pap smear. Excessive blood and inflammation are known to interfere with specimen ade-
quacy in some liquid-based Pap testing.3-7 The 2 commonly used liquid-based cytology technologies,
ThinPrep (Hologic, Marlborough, Mass) and BD SurePath (BD Diagnostics‥TriPath, Burlington, NC),
differ in their methods of producing thin-layer Pap slides.8,9 Some authors, based on their experience with

Corresponding author: Douglas Schneider, MD, Department of Pathology, St. Elizabeth’s Medical Center, MMR 3, 736 Cambridge Street, Boston,
MA 02135; Fax: (617) 562-7853; Douglas.Schneider@caritaschristi.org
1 2
Department of Pathology, St. Elizabeth’s Medical Center, Boston, Massachusetts; Department of Pathology, Tufts Medical Center, Boston,
Massachusetts
Received: May 21, 2010; Revised: June 16, 2010; Accepted: June 17, 2010
Published online in Wiley Online Library (wileyonlinelibrary.com)
DOI: 10.1002/cncy.20096, wileyonlinelibrary.com

Cancer Cytopathology Month 00, 2010 1

Original Article
these technologies, have raised questions regarding the
relative capacities of ThinPrep and BD SurePath for
handling potentially limiting factors, particularly with
regard to specimen adequacy.10,11,12 We have previ-
ously shown marked differences in the ability of these 2
technologies to effectively deal with the presence of ex-
cessive blood.13 This study recreates test conditions of
excessive mucus and examines the ability of the Thin-
Prep and BD SurePath methods to process specimens
containing various amounts of cervical mucus.
MATERIALS AND METHODS
Human cervical epithelial cells were collected by combin-
ing the cellular residues from 15 BD SurePath vials after
routine Pap test processing was completed. The cells were
washed twice in deionized water, and the resulting cell
button resuspended in 6 mL of normal saline. This proce-
dure yielded sufficient squamous cells to produce richly
cellular SurePath and ThinPrep Pap test slides. The resus-
pended cells were added to 5 BD SurePath and 5 Thin-
Prep liquid Pap test vials in 100 lL aliquots. This
procedure was repeated for each of 10 test runs. A collec-
tion of pooled cervical mucus was prepared by harvesting
mucus from the top of the Prep Stain Density Reagent
material in mucus-rich Pap specimens found during the
routine BD SurePath cell-enrichment process. The pooled
mucus was stable at room temperature for several days,
allowing time to collect sufficient amounts for testing. To
simulate clinical conditions of excessive mucus, aliquots
of the pooled mucus preparation were added to test vials
containing the previously dispensed squamous cells in
amounts of 250 lL, 500 lL, 1000 lL, and 2000 lL.
These volumes were chosen to range from roughly physio-
logical amounts encountered during the BD Surepath
cell-enrichment process in mucus-rich specimens to an
amount representing an attempt to overwhelm the BD
SurePath system with mucus. All test vials were routinely
processed on their respective BD SurePath and ThinPrep
instruments. For the purposes of this study, coated slides
prepared in the laboratory were used for the SurePath
tests, rather than the commercially available SurePath Pre-
Coat slides. The Pap slides were evaluated for adequacy of
cellularity by the first author, who used recommendations
provided in The Bethesda System for Reporting Cervical
2 Cancer Cytopathology
Cytology.1 The number of squamous cells in 10 40

high-power fields per slide were counted manually, read-
ing across the horizontal diameter of the test area to
include the center, and rendering an average cell count per
high power field. The average cell counts resulting from
the 2 Pap test systems in 10 test runs were compared.
Because of the differing diameters of the BD SurePath
and ThinPrep test areas,13 mm and 20 mm, respectively,
the Bethesda System Guidelines for Estimating Cellular-
ity of Liquid-based Preparations1 were used to ensure that
the cellularity values presented for BD SurePath and
ThinPrep specimens were directly comparable. The Stu-
dent t test was used in assessing differences in average cel-
lularity between specimens. Endocervical cells were not
evaluated because the focus of this study was to determine
the effects of mucus on specimen adequacy as determined
by the cellularity of the squamous component.
RESULTS
Representative cytology slide images resulting from the
addition of various amounts of mucus are shown for BD
SurePath and ThinPrep specimens in Figure 1. The nu-
merical results of the average cell counts from the 10 indi-
vidual test runs are given in Table 1, with the data
presented in graphical form in Figure 2.
The BD SurePath test specimens showed no dimin-
ishment of cellularity from the addition of any of the ali-
quots of mucus. Abundant cellularity was observed even
in the specimens with the maximum amount of added
mucus (2000 lL). In test runs number 3 and number 4,
the initial SurePath slides (without added mucus) showed
significantly lower cellularity than any of the other initial
SurePath test slides. This appeared to be the result of a
degree of deficiency in the ‘‘in-house-prepared’’ slide coat-
ing in these 2 instances. Interestingly, most of the BD
SurePath specimens showed increases in cellularity with
added mucus, presumably because of the release of squa-
mous cells from the mucus (P ¼ .01 for mucus aliquots of
1000 lL and 2000 lL). Unexpectedly, we were unable to
overwhelm the BD SurePath system with the maximum
amount of added mucus. The ThinPrep test specimens
invariably showed a loss of cellularity upon the addition
of mucus. The addition of the first aliquot of mucus (250
lL) resulted in a 61% average decrease in cellularity (P <
.0001). The largest aliquot of mucus (2000 lL) produced
Month 00, 2010
 Excessive Mucus in Liquid-Based Cytology/Kenyon et al

FIGURE 1. Gross and microscopic views of BD SurePath (SP) and ThinPrep (TP) slides (left and right columns, respectively) were
prepared from pooled cervical epithelial cells with increasing amounts of added mucus. (A) SP slide with no added mucus (10
);
(B) TP slide with no added mucus (10
) showing similar cellularity to slide A; (C) SP slide with 250 lL added mucus (40
) show-
ing abundant cellularity; (D) TP slide with 250 lL added mucus (40
) showing obscured morphology from entrapment of cells in
mucus; (E) SP slide (10
) with 500 lL added mucus showing abundant cellularity; (F) TP slide (10
) with 500 lL added mucus
showing large areas with nearly complete absence of epithelial cells; (G) SP slide (40
) with 1000 lL added mucus showing
abundant cellularity; (H) TP slide (40
) with 1000 lL added mucus showing reduced cellularity and entrapment of cells in mucus;
(I) SP slide (10
) with 2000 lL added mucus with an ample number of cells; (J) TP slide (10
) with 2000 lL added mucus show-
ing entrapment of cells in mucus and large areas with nearly complete absence of cells.

Cancer Cytopathology Month 00, 2010 3

Original Article

Table 1. Comparison of the Average Cell Count per High

Power Field (HPF) Adjusted for Test Area Diameter

Set Mucus Cells per HPF

Added (lL) TP SP
1 0 52.1 70.8
250 8.8 77.0
500 5.5 67.0
1000 3.6 71.0
2000 6.9 70.0
2 0 26.3 63.3
250 20.4 68.0
500 7.1 71.0
1000 6.2 91.4
2000 7.8 88.0 FIGURE 2. Comparison of SurePath and ThinPrep average
3 0 20.4 8.7
cell counts per High Power Field (HPF) show increasing
250 16.4 31.2
amounts of added mucus (adjusted for test area diameter).
500 10.7 43.0
The mean and standard deviation of the average cell count
1000 6.6 46.4
per high power field for ThinPrep and SurePath cytology
2000 3.6 41.9
specimens with the addition of 0 lL, 250 lL, 500 lL,
4 0 32.0 14.4
250 12.6 33.4 1000 lL, and 2000 lL are plotted. The ThinPrep values were
500 8.5 38.4 adjusted according to the Bethesda Guidelines for Estimating
1000 5.0 48.5 Cellularity.4 The data are a compilation of 10 separate experi-
2000 3.6 63.0 mental runs.
5 0 47.6 56.0
250 14.5 60.3
500 3.8 60.5
1000 5.0 73.9
2000 2.4 67.4 DISCUSSION
6 0 24.2 44.4
250 10.7 67.1 Decreased ‘‘unsatisfactory’’ rates for the ThinPrep Pap
500 7.8 66.1 test, as compared with conventional smears, have been
1000 5.0 73.7
2000 3.8 80.0 reported.14-17 Conversely, our laboratory experience has
7 0 23.7 54.8 shown problems in the uniformity of cell deposition on
250 14.5 68.2
500 11.4 70.1 ThinPrep slides in some conditions, suggesting regional
1000 4.3 88.2 clogging of ThinPrep filter pores with the potential for
2000 6.2 92.3
8 0 41.7 54.0 impacting the detection rate of cervical lesions. Published
250 7.1 60.9 studies have also indicated the possibility of ‘‘plugging’’ of
500 5.9 57.0
1000 3.6 70.9 the ThinPrep filter membrane resulting in under-repre-
2000 4.0 77.3 sented or unsatisfactory Pap tests.3,4,18,19 Factors involved
9 0 56.4 43.2
250 33.9 54.9
in the obstruction of the membrane include blood,
500 18.0 56.0 inflammation, mucus, cellular debris, and tumor diathe-
1000 5.0 51.3
2000 4.5 58.7
sis. Specific to this study, mucus can result in ThinPrep
10 0 46.9 30.5 slides with ‘‘holes’’ or areas devoid of cells.4 One study
250 7.8 44.8
500 9.5 52.3
looking at reprocessing of unsatisfactory ThinPrep Pap
1000 7.6 59.6 tests found that of the unsatisfactory Pap tests remaining
2000 4.5 46.4
after reprocessing, 20.6% were caused by mucus.3
Another study reported 37.9% of unsatisfactory ThinPrep
Pap tests to be due to mucus before reprocessing proce-
an average decrease in cellularity of 87%. ThinPrep slides dures were applied.20
with added mucus often showed large areas of the filters The issue of decreased cell retrieval or uneven cell
with nearly complete absence of epithelial cells. Other distribution in ThinPrep Pap tests with excessive mucus,
areas showed compromised morphology from entrap- as well as blood and inflammation, was essentially elimi-
ment of cells in mucus (Fig. 1). nated in our laboratory upon switching to the BD

4 Cancer Cytopathology Month 00, 2010


SurePath liquid-based technology. As a result we became
curious to see to what extent these 2 technologies differ in
their ability to handle mucus-rich specimens. This small
study examines this issue using recreated mucus-rich
specimens.
The results show that specimens processed in the
BD SurePath system had effectively no diminution of cel-
lularity with any amount of added mucus. Even when mu-
cus appeared on the slides after amounts were added
sufficient to exceed the capacity of the cell enrichment
process, there was no compromise of cellular adequacy
and no obscuring of cellular morphology. Indeed, cellu-
larity increased in some specimens, presumably from the
release of cells from mucus. This finding raises questions
about the practice of removing gross mucus from the
specimen container before processing, suggesting the
possible loss of entrapped cells.
In contrast, the ThinPrep specimens invariably
showed a loss of cellularity upon the addition of the first
aliquot of mucus. The ThinPrep slides exhibited large
areas devoid of cells consistent with filter membrane plug-
ging. When mucus was transferred to the slide, those cells
trapped in mucus were morphologically compromised.
The results are understandable given the differences
in technology between the BD SurePath and ThinPrep
Pap test systems as posted on company internet sites.21,22
BD SurePath uses no filters and employs a ‘‘proprietary
cell enrichment process (that) separates and reduces
obscuring debris (eg, blood, mucous) and inflammatory
cells.’’ The ‘‘obscuring debris’’ is trapped in a gradient
density material that is removed, after which a second cen-
trifugation produces an enriched cell pellet. The cells set-
tle onto coated slides called PreCoat slides. Conversely,
‘‘the ThinPrep 2000 uses a computerized process and
patented membrane technology that controls dispersion,
collection, and transfer of diagnostic cells from the sample
to the slide.’’ After rotation within the sample vial to sepa-
rate debris and disperse mucus, ‘‘a gentle vacuum collects
cells on the exterior surface of the Filter membrane.’’ The
cells are then transferred by gently pressing the membrane
against the microscope slide. It is during the vacuum col-
lection process that the ThinPrep technology appears vul-
nerable to excess mucus, inflammation, or blood, which
can compete with diagnostic cells in the collection process
and slow the flow rate, thus terminating collection. Re-
covery of unsatisfactory ThinPrep specimens has been
Cancer Cytopathology Month 00, 2010
Excessive Mucus in Liquid-Based Cytology/Kenyon et al
described using off-label techniques,3,4,6,20,23 but this
entails added expense and labor. Nevertheless, some have
found reprocessing of unsatisfactory ThinPrep Pap tests
to be a necessity.4 The issue of unevenly or deficiently
coated slides in the SurePath system has been eliminated
by the use of company’s SurePath PreCoat slides. In our
experience at present, the only unsatisfactory BD Sure-
Path specimens are those that are truly hypocellular.
Further studies appear indicated to determine the
best practice for the prevention of potential false-negative
results when processing mucus-rich specimens with the
ThinPrep methodology.
CONFLICT OF INTEREST DISCLOSURES
The authors made no disclosures.
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