The "Inconclusive--possible high grade epithelial abnormality" category in Papanicolaou smear reporting

The association of atypical squamous cells, cannot exclude a high grade squamous intraepithelial lesion, hyperchromatic crowded groups and high grade squamous intraepithelial lesions involving endocervical glands

BACKGROUND

Hyperchromatic crowded groups (HCGs) are often classified as atypical squamous cells, cannot exclude a high grade squamous intraepithelial lesion (ASC-H) on ThinPrep Pap tests. This study reports on the association of HCG's with high grade squamous intraepithelial lesions (HSIL) involving endocervical glands.

METHODS

Over a 3-year period (January 1, 2018-December 31, 2020), 115 (0.2%) of 63,817 Pap tests were diagnosed as ASC-H. Histologic follow-up was available in 76 (66%) cases; 42 (55%) cervical biopsies; and 34 (45%) cervical cones/LEEPs.

RESULTS

Based on the histologic results, 49 ASC-H cases showed HSIL/CIN 3 and form the basis of this study. ThinPrep Pap tests showed two cell patterns; atypical immature squamous metaplastic cells and HCGs, each of which was difficult to distinguish from HSIL. On histologic correlation all 10 ASC-H Pap Tests with individual atypical immature squamous metaplastic cells showed HSIL/CIN 3 without endocervical gland involvement and 37 (95%) of the 39 Pap Tests with HCGs showed HSIL/CIN 3 with endocervical gland involvement.

CONCLUSION

The results of this study support the premise that a subset of HCGs represent endocervical gland involvement by HSIL as opposed to a glandular lesion; in particular endocervical adenocarcinoma in-situ.

Evaluating the Existence of Small Compressed Binucleated Squamous Cells in ASC-H

Purpose:

To evaluate the legitimacy of a diagnosis of ASC-H in 5 cases which were followed up monthly for over 2 years with both cytology and HPV testing.

Methods:

Some 5 cases out of a total of 25.0 self-sampled Pap test patients diagnosed as ASC-H provided 119 specimens over 2 years, with HPV-DNA testing perormed using a E6 primer.

Results:

Cases 1, 2 and 3 showed SIL after the ASC-H diagnosis, while cases 4 and 5 showed and maintained NILM. Cases 1, 2 and 3 were further characterized by small atypical compressed binucleated cells, in which HPV was detected by in situ PCR. Case 4 showed a high N/C ratio in cells in sheets with a mild increase in chromatin. Case 5 demonstrated a high N/C ratio in small cells with no increase in chromatin.

Conclusion:

The finding of a compressed binucleated cells can define the difference between degenerated endocervical columnar cells and small atypical cells suggestive of HSIL. When small compressed binucleated squamous cells are detected, there may be a chance of continuing HPV infection and undetected SIL.

Clinical significance of atypical squamous cells cannot exclude high grade squamous intraepithelial lesion with histologic correlation-: a 9-year experience

Atypical squamous cells, cannot exclude high grade squamous intraepithelial lesion (ASC-H) is a recognized category in the 2001 Bethesda Nomenclature System for cervical cytology. Although current ASCCP guidelines recommend colposcopic follow-up, more recent studies are suggesting prior triage for HPV-DNA analysis. We report on our experience at the University of Wisconsin Hospital and Clinics. From January 1, 2003 through December 31, 2011 (9-y), the cytopathology laboratory processed 109,424 Pap Tests, of which 281 (0.26%) were diagnosed as ASC-H. Tissue follow-up was available in 181 (64%) of these cases, of which 45 (25%) were negative/cervicitis, 41 (23%) were CIN 1, 36 (20%) were CIN 2 and 59 (32%) were CIN 3. Stratification by age groups showed a higher percentage of high grade (CIN 2+) lesions (65%) in the premenopausal age group as compared with high grade lesion (35%) in the postmenopausal age group, whereas negative/CIN1 biopsies were more common in postmenopausal (65%) as compared to premenopausal (44%) women. Our data support the use of colposcopy in the management of women with ASC-H on Pap Tests. However, in the older age group, prior HPV-DNA testing may be of benefit to better identify those women at risk for high grade lesions.

Follow-up outcomes in a large cohort of patients with human papillomavirus-negative ASC-H cervical screening test results

Limited follow-up data are available on patients with cervical cytology results of atypical squamous cells, cannot exclude a high-grade intraepithelial lesion (ASC-H), who test negative for high-risk human papillomavirus (hrHPV). Between June 2005 and December 2010, 885 patients were identified with ThinPrep results of Hybrid Capture 2 (HC2) hrHPV-negative cervical ASC-H liquid-based cytology and follow-up histopathology or cytology results extending to September 2011. Of the 885 patients with available follow-up results, 549 (62.0%) had at least 1 histopathologic result during the entire follow-up period, whereas 336 (38.0%) had only cytologic follow-up documented. In an average follow-up period of 29 months, 14 (1.6%) of 885 patients with HPV-negative ASC-H results showed evidence of high-grade cervical intraepithelial neoplasia (CIN2/3). No cases of invasive cervical cancer were diagnosed. Four of 14 patients with HPV-negative ASC-H results with follow-up diagnoses of CIN2/3 had a history of earlier CIN2/3 diagnoses before HPV-negative ASC-H results. Follow-up of patients with HPV-negative ASC-H results using methods specified in this study yielded low rates of detectible CIN2/3 and no diagnoses of cervical cancer. Triage of study patients with HPV-negative ASC-H results to routine HPV and cytology cotesting at 1 year was a safe follow-up option.

Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion: diagnostic features in surepath™ cervical samples

This study was undertaken to identify the situations in which a diagnosis of "Atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion (ASC-H)" is offered in SurePath™ cervical samples and to identify cytological criteria helpful in predicting high-grade disease. 2,335 (3.4%) SurePath samples reported as atypical squamous cells (ASC) over a period of 2 years, including 1,112 cases with known hrHPV status were retrieved. 105/1,112 cases were categorized into ASC-H, and slides were available for review in 88/105 cases. These 88 samples were divided into two categories based on follow-up histological outcome and hrHPV status-category A: cases with CIN2+ lesions on follow-up (n = 48) and category B: cases with ≤CIN1 lesions or hrHPV negative status (n = 40). 78% (82/105) cases of ASC-H tested positive for hrHPV. Overall CIN2+ lesions were found in 50.3% (53/105) cases. Of 88 cases reviewed, HCGs were noted in 56.3% (27/48) cases in category A and 75% (30/40) cases in category B. Dispersed metaplastic cells and scattered small atypical cells were seen in 37.5% (18/48) cases in category A and 12.5%(5/40) in category B. The majority of cases with dispersed atypical cells had <20 cells/sample and cases with HCGs had <10 HCGs per sample. The majority of the cases reported as ASC-H contained HCGs. Of these groups with nuclear crowding, disorganization and those with steep edges ("blocks") are likely to predict high-grade disease. The samples with only dispersed atypical cells had <20 cells/sample in majority of cases. In these, a disproportionate and especially high nuclear: cytoplasmic ratio and irregular chromatin were the most useful features in predicting high-grade disease.

A review of histological outcomes from peri-menopausal and post-menopausal women with a cytological report of possible high grade abnormality: an alternative management strategy for these women

AIM

To investigate the histological outcomes of women with cytological reports of possible high grade abnormality and to determine if patient age may be a clinically significant factor in determining the presence of high grade disease for this cytological category.

METHODS

Using annual quality reports supplied by the Queensland Pap Test Register, the histological outcomes for 2054 women with possible high grade cytological reports over a 4 year period were investigated to determine the clinical significance of this category in older aged women. Women in the total study group were aged between 16 and 84 years and outcomes were divided into women aged under 40 years and 40 years and over as well as those aged under 50 years and 50 years and over. Cytomorphological features were compared to determine if there were any significant differences between the outcome groups.

RESULTS

The histological confirmation rate for high grade disease for all women was 53.1%. The incidence of histologically confirmed high grade disease was significantly higher in women aged under 40 years (59.7%) compared to women aged 40 years and over (40.3%) (p = 0.001). This was also true for women aged under 50 years compared to those aged 50 years and over (55.8% versus 37.5%) (p = 0.001). When the smears from these women were reviewed, a predominance of mature intermediate and superficial cells was evident in the background of the majority of slides in all histological outcome categories. Many of the smears in the negative outcome group showed reactive, reparative or inflammatory changes.

CONCLUSIONS

The currently mandated Australian management guideline for women with a cytology report of possible high grade disease is referral for colposcopic and histological examination. Since the incidence of high risk human papillomavirus (HPV) decreases with age, a less invasive strategy may be to test women in these older age groups for high risk HPV before proceeding to colposcopy.

Atypical squamous cells, cannot exclude a high-grade intraepithelial lesion and its clinical significance in postmenopausal, pregnant, postpartum, and contraceptive-use patients

BACKGROUND

Previous studies have confirmed the low predictive value of a diagnosis of atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion (ASC-H) in a Papanicolaou (Pap) smear for subsequent high-grade dysplasia in the postmenopausal age group. It appears plausible that the decrease in estrogen inherent in the postmenopausal state likely produces reactive cytologic atypia, which is misinterpreted as ASC-H. The change in hormone levels observed in pregnant patients, postpartum patients, and contraceptive users, as a corollary, potentially could create a similar diagnostic dilemma. In the current study, the impact of age and altered hormone status on the frequency of ASC-H was assessed to answer the following questions: Is the low predictive value of ASC-H in postmenopausal women an age-related phenomenon, and do other states that result in decreased levels of estrogen relative to progesterone have a similar association?

METHODS

Pap smears that were diagnosed as ASC-H were divided into postmenopausal, pregnant, postpartum, and contraceptive-use categories. Each Pap smear slide was reviewed to assess the degree of atrophy and the character of atypical cells. The frequency of high-grade follow-up (histology and/or Digene Hybrid Capture II) in the postmenopausal group was compared with the frequency of high-grade follow-up in the pregnant, postpartum, and contraceptive-use categories using the chi-square test. The pregnant, postpartum, and contraceptive-use categories also were compared statistically among each other with the chi-square test.

RESULTS

In total, 195 cases met the criteria for study inclusion. The percentage of patients who had subsequent high-grade follow-up was 22.5% in the postmenopausal group, 79.6% in the pregnant group, 66.7% in the postpartum group, and 60% in the contraceptive-use group. When these data were subjected to the chi-square test, there was a statistically significant difference (P<.0001) between the predictive value of subsequent high-grade follow-up in the postmenopausal group compared with the other patient groups. When the chi-square test was applied to the intercomparison of the pregnant, postpartum, and contraceptive-use categories, there were no significant differences (P > .05) in high-grade follow-up between any of these groups.

CONCLUSIONS

The diagnosis of ASC-H in postmenopausal Pap smears has a low predictive value in the subsequent diagnosis of high-grade squamous lesions in stark contrast to the pregnant, postpartum, and contraceptive-use categories. This suggests that age rather than hormone alterations affects the capacity of ASC-H to predict subsequent high-grade squamous intraepithelial lesions. In addition, there are no definite cytomorphologic criteria that can be used to distinguish reliably between benign cellular changes and possible high-grade squamous lesions in these Pap smears. Digene Hybrid Capture II testing, although helpful, does not have 100% correlation with subsequent tissue/Pap smear follow-up and cannot be used alone to triage this group of women for colposcopy.

Patients with negative cervical biopsies after papanicolaou test interpretations of "atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion": comparative longitudinal follow-up

Approximately half of women with a Papanicolaou (pap) test interpretation of "atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion" (ASC-H) will have less than a high-grade dysplasia diagnosed on their follow-up cervical biopsy sample. Herein, we compared the follow-up findings in a group of women with a negative cervical biopsy after a pap test interpretation of ASC-H (study group) with those of a randomly selected control group of women whose pap tests were interpreted as "negative for intraepithelial lesion or malignancy" during the same period. The diagnoses in every follow-up sample in the control and study groups were tabulated. Patients with previous ASC-H or high-grade squamous intraepithelial lesion interpretations, and/or high-grade cervical intraepithelial neoplasia (CIN) diagnoses, were excluded. Both groups were then statistically compared regarding the diagnostic frequencies of each of the Bethesda 2001 categories and CIN grades. Of the 122 patients with ASC-H interpretations and documented histologic follow-up, the first follow-up biopsy was negative for dysplasia in 20 (16.4%). Seventy-six follow-up samples (70 pap tests, 6 biopsies) were obtained from these 20 patients. In the control group of 262 women with pap tests interpreted as "negative for intraepithelial lesion or malignancy," 641 follow-up samples (629 pap tests, 12 biopsies) were obtained. Patients in the study group were significantly more likely than their control group counterparts to have a follow-up (1) cytologic and/or histologic abnormality (23/76 vs 76/641, respectively; P = .00006), (2) "atypical squamous cells of undetermined significance" (ASC-US) interpretation (13/76 vs 43/641; P = .005), and (3) CIN grade 1 diagnosis (4/76 vs 10/641; P = .05). Approaching statistical significance was the comparatively increased frequency of CIN grade 2 to 3 diagnoses in the study group (2/76 vs 2/641; P = .058). If the analysis is restricted to 1 follow-up sample (the most severe) per patient, patients in the study group were still more likely than those in the control group to have a follow-up cytologic and/or histologic abnormality (12/20 vs 40/262; P = .0002), ASC-US interpretation (6/20 vs 22/262; P = .008), and follow-up CIN grade 2 to 3 diagnosis (2/20 vs 2/262; P = .03). It is concluded that patients whose cervical biopsies are devoid of dysplasia after an ASC-H interpretation still require close surveillance and follow-up because their risk of being diagnosed with follow-up cervical abnormalities is significantly above baseline.

Human papillomavirus (HPV) in atypical squamous cervical cytology: the Invader HPV test as a new screening assay

In surveillance for cervical neoplasia, a diagnosis of cytologically atypical squamous cells of undetermined significance (ASCUS) presents a significant clinical issue, often dependent on testing for high-risk (HR) human papillomavirus (HPV) for the triage of patients. HPV type 16 now appears to be a critical concern in the follow-up of patients with ASCUS. The Invader HPV (Inv2) test, by Third Wave Technologies, Inc., is a recently developed analyte-specific reagent assay that uses probe sets for the detection of 14 HR HPV subtypes. These probe sets are A5/A6 (HPV types 51, 56, and 66), A7 (HPV types 18, 39, 45, 59, and 68), and A9 (HPV types 16, 31, 33, 35, 52, and 58). This report describes the performance characteristics of the Inv2 test in the screening of ASCUS cervical cytology specimens and correlates the results of the Inv2 test with those of the Hybrid Capture II HPV (HC2) test by Digene. The linear array HPV genotyping test (Roche Molecular Systems) was used as a reference method for the testing of samples with discordant results. Ninety-four Pap smear samples with a cytological diagnosis of ASCUS and 39 samples with a negative diagnosis were tested. The results of the Inv2 test demonstrated a good (86.6%) concordance with those of the HC2 test, with an overall sensitivity and specificity of 96% for the Inv2 test. Additionally, the Inv2 assay, which offers high-throughput, semiautomated DNA extraction, allows the subgrouping of HPV types by differential probe sets, could provide a useful test for screening for HPV, and has the potential to provide an improved means of risk stratification and the selection of patients for further HPV subtyping.

Human papillomavirus testing and molecular markers of cervical dysplasia and carcinoma

Cervical cancer is the second most common cancer in women worldwide. Human papillomavirus (HPV) is the etiologic agent for the vast majority of premalignant and malignant lesions, and high-risk HPV types can be detected in almost all cases of cervical dysplasia and carcinoma. HPV testing has been widely adopted for the triage of patients after a cervical cytology screening test (Papanicolaou smear or liquid-based cervical cytology such as ThinPrep or SurePath) interpretation of atypical squamous cells of undetermined significance (ASCUS), and HPV testing is increasingly used for screening in conjunction with cervical cytology. Although cervical cytology is a highly effective screening test for cancer, it has limited specificity for clinically significant lesions in cases with low-grade cytologic abnormalities. Up to a quarter of all patients may have a false-negative result on the basis of cervical cytology testing alone. This review focuses on HPV testing methods and molecular markers and their clinical relevance. HPV testing and surrogate molecular markers of HPV infection (p16INK4a) may help identify cases that are associated with underlying high-grade premalignant or malignant lesions and may also reduce aggressive treatment of patients with low-grade lesions.

A three-armed trial of the ThinPrep Imaging System

We compared the performance of the ThinPrep (TP) Imaging System (TIS) with manual reading of TP slides (TPM) and with manual reading of the paired conventional Pap smear (PS) in terms of sensitivity for and positive predictive value (PPV) of high-grade disease and productivity. The study consisted of 11,416 routine PS and paired TP slides as well as 103 confirmed abnormal TP slides. In terms of sensitivity for the detection of biopsy-confirmed high-grade disease, overall there was no statistically significant difference between TIS-screened TP (TPI) and TPM (81.1% vs. 86.8%). For the routine cases, TPI was significantly more sensitive than PS (73.4% vs. 57.8%). In terms of PPVs for the cytologic prediction of high-grade disease, there was no statistically, significant difference among TPI, TPM, and PS (75.6%, 73.9%, and 84.6%). For cytologic reports of possible high-grade disease, the PPVs were equivalent for TPI (45.0%) and TPM (37.0%) and there was no significant difference in PPVs between TPI and PS (61.3%). For TP slides, TIS screening showed a 27% productivity gain when compared with manual screening and a 54% productivity gain when compared with manual screening of PS slides. Use of TIS showed productivity benefits when compared with TPM and both productivity and sensitivity benefits over use of PS.

Cervical cytology of atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion (ASC-H): characteristics and histologic outcomes

BACKGROUND

The 2001 Bethesda System category of atypical squamous cells (ASC) denotes changes suggestive, but inconclusive for, a squamous intraepithelial lesion (SIL). ASC is subcategorized as: 1) "undetermined significance (ASC-US)," when changes suggest low-grade or indeterminate-grade SIL and 2) "cannot exclude high-grade squamous intraepithelial lesion (ASC-H)," when a cancer precursor is suspected.

METHODS

To better define the characteristics of ASC-H, the authors analyzed and compared human papillomavirus (HPV) testing data and outcomes after 2 years for participants in the Atypical Squamous Cells of Undetermined Significance Low-Grade SIL Triage Study (ALTS), a randomized trial of 5060 women.

RESULTS

Among women with thin-layer cytology findings of ASC-H, 84% tested positive for HPV, 50% (95% confidence interval [95% CI], 41%-60%) were diagnosed with cervical intraepithelial neoplasia (CIN) type 2+, and 30% (95% CI, 22-39%) were diagnosed with CIN3+. Positive HPV tests and diagnoses of CIN2+ and CIN3+ were found to be more common among women with ASCH compared with those with ASC-US, but the highest frequencies were found to be associated with high-grade SIL. For women age < 35 years with ASC-H, HPV detection exceeded 85%, whereas only 4 of 10 women (40%) age >/=35 years tested positive for HPV (P = 0.009).

CONCLUSIONS

A finding of ASC-H seems to confer a substantially higher risk for CIN2+ and CIN3+ than ASC-US. Immediate colposcopy may be the appropriate management for young women with ASC-H, but the utility of HPV testing for managing older women with ASC-H requires additional study.

Analyses of atypical squamous cells refined by the 2001 Bethesda System: the distribution and clinical significance of follow-up management

This study was conducted to analyze the clinical significance of follow-up diagnostic methods of atypical squamous cells (ASC) (the 2001 Bethesda System) cases according to age. A computerized search of the cytology database was performed to retrieve all cases diagnosed as ASC from 2001 to 2003. The pathologic reports for all follow-up diagnoses were reviewed. We divided the patients into two groups according to their age, younger than 50 years of age and 50 years and older, and follow-up diagnoses were compared between the two groups. ASC was identified in 1035 (2.0%) of 49,882 women screened, and a total of 914 patients were eligible. In atypical squamous cells of undetermined significance (ASC-US) cases, colposcopically directed biopsy showed CIN I (CIN is cervical intraepithelial neoplasia) or higher grade lesions in 34.9% of cases younger than 50 years of age and in 17.4% of cases 50 years and older (P= 0.000). However, repeat Pap smears and human papillomavirus DNA testing showed no differences between the two groups. In contrast, the three methods did not exhibit significant difference between the two groups in patients with atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H) (P= 0.743). Colposcopically directed biopsy for the ASC-US was more useful in patients younger than 50 years of age than in those who were 50 years and older. It is suggested that age should be considered in deciding follow-up diagnostic methods in patients with ASC-US.

Clinical significance of cytologic diagnosis of atypical squamous cells, cannot exclude high grade, in perimenopausal and postmenopausal women

We used cytohistologic correlation to determine the clinical significance of atypical squamous cells, cannot exclude high grade (ASC-H) in perimenopausal and postmenopausal women. A computer search identified 250 Papanicolaou smears from women older than 45 years with a diagnosis of ASC- H. Cases were considered perimenopausal (45 to < 55 years; 150 cases) and postmenopausal ((3)55 years; 100 cases). No follow-up data were available for 33 cases, which were excluded. The remaining 217 cases (perimenopausal, 127; postmenopausal, 90) had surgical or cytologic follow-up. Results of follow-up colposcopic biopsy were available for 176 (81.1%) and cytology for 41 (18.9%) women. Follow-up results were as follows: perimenopausal women, negative, 50 (39.4%); mild dysplasia (low-grade squamous intraepithelial lesion [LSIL]), 46 (36.2%); high-grade dysplasia (high-grade SIL [HSIL]); 28 (22.0%); and ASC of undetermined significance (ASC-US), 3 (2.4%); postmenopausal women, negative, 52 (58%); LSIL, 31 (34%); HSIL, 5 (6%); and ASC-US, 2 (2%). The diagnosis of ASC-H in postmenopausal women usually is associated with LSIL or a negative diagnosis on follow-up, suggesting a less aggressive surveillance and treatment regimen is needed for postmenopausal women with ASC-H.

The significance of “low-grade squamous intraepithelial lesion, cannot exclude high-grade squamous intraepithelial lesion” as a distinct squamous abnormality category in Papanicolaou tests

BACKGROUND

Early cytologic detection and treatment of high-grade squamous intraepithelial lesion (HSIL) is critical to cervical cancer prevention. The term atypical squamous cells (ASC), cannot exclude HSIL (ASC-H) was introduced in 2001 in the Bethesda System (TBS 2001) to define changes suggestive, but not diagnostic, of HSIL in the absence of unequivocal squamous intraepithelial lesion (SIL). Previous studies showed that women with ASC-H cytology are at an increased risk of harboring underlying histopathologic HSIL. TBS 2001, however, did not address the significance of finding ASC-H changes in a background of unequivocal low-grade SIL (LSIL). There may be a tendency for cytologists to lump these changes with either LSIL or HSIL, depending on their level of comfort. In their laboratory, the authors have referred to these changes as "LSIL, cannot exclude HSIL" (LSIL-H).

METHODS

Between July 2001 and July 2003, all Papanicolaou (Pap) tests that were obtained by using the ThinPrep technique were retrieved from the computer data base at the authors' institution. All categories of squamous cell abnormalities, including LSIL-H, were evaluated for their incidence and follow-up diagnoses of HSIL and more severe lesions (HSIL +). All patients had a minimum of 2 year follow-up by biopsy and cytology (range, 2-4 years).

RESULTS

LSIL-H comprised 0.15% (n = 194) of all Pap tests (n = 129,911) that were evaluated during the study period. Follow-up biopsy was available on 59 patients (30.4%), which showed HSIL + in 40.7% of patients. This rate of associated HSIL + differed significantly from that of LSIL (13%; P < .001) and HSIL (74%; P < .001), but was similar to that of ASC-H (44.6%).

CONCLUSIONS

The results from this study showed that patients with cytologic diagnoses of LSIL-H had an intermediate risk of harboring histopathologic HSIL +. This risk was similar to ASC-H but fell between the low risk associated with ACS-US and LSIL and the high risk associated with HSIL cytologic diagnoses. The authors believe that LSIL-H should be considered as a distinct cytologic diagnostic interpretation and should be separated from LSIL and HSIL. Although LSIL-H does not represent a unique biologic entity, it has clinical usefulness because of its high positive predictive value for HSIL + lesions.

Reflex high-risk human papilloma virus DNA test is useful in the triage of women with atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion

This study is aimed to investigate the role of reflex high-risk human papilloma virus (HPV) DNA testing as an alternative triage method to colposcopy for women with atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H) on Papanicolaou (Pap) tests. Reflex HPV DNA testing using Hybrid Capture II method was carried out on 88 women with ASC-H diagnosed by Thin Prep Pap test. Correlation with follow-up biopsies was available on 42 of these patients. The reflex HPV DNA test showed an overall positive rate of 67% and negative rate of 33% in 88 patients with ASC-H. Using age 30 as the cut off point, the positive rate had increased to 83.3% (35/42) in patients 30 yr or younger, while the positive rate for patients older than 30 yr had decreased to 52.2% (24/46). Follow-up colposcopic biopsy results were available in 35 of 59 HPV-positive women, which revealed 15 (43%) high-grade squamous intraepithelial lesions (HSIL), 12 low-grade squamous intraepithelial lesions (LSIL), and 8 negative for dysplasia. In 7 HPV-negative patients, the follow-up biopsies showed no evidence of HSIL or LSIL. Correlation between clinical risk factors and the HPV results demonstrated no significant differences in HPV positivity between the high-risk and low-risk patients. The high sensitivity (100%) and negative predictive rate (100%) in detecting HSIL in our study provide strong evidence that, instead of automatic referral to colposcopy, reflex HPV DNA testing may be used as an alternative triage method for women diagnosed with ASC-H on Thin Prep Pap test, especially for women older than 30 yr of age.

Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion

BACKGROUND

Current guidelines recommend colposcopy rather than high-risk human papillomavirus (HPV) testing for the evaluation of abnormal cervical cytology interpreted as "atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion" (ASC-H) based on data from the Atypical Squamous Cells of Undetermined Significance/Low-Grade Squamous Intraepithelial Lesion (ASCUS/LSIL) Triage Study (ALTS), which indicated that ASC-H had a significantly greater frequency of high-risk HPV positivity and underlying high-grade squamous intraepithelial lesions (HSIL) compared with ASCUS. The cytologic interpretations in the ALTS were expert consensus diagnoses rather than routine, single-pathologist readings.

METHODS

The authors conducted a comparative analysis of Hybrid Capture 2 high-risk HPV positivity and frequency of histologically diagnosed HSIL for ASC-H and ASCUS to evaluate the performance of ASC-H as a cytologic interpretation subcategory and the potential utility of HPV testing for colposcopy triage of ASC-H in routine practice.

RESULTS

Sixty-four of 96 patients with ASC-H (66.7%) were HPV-positive compared with 484 of 1079 patients with ASCUS (44.9%). Among the patients who had histologic follow-up, HSIL was identified in 18 of 45 patients (40.0%) with HPV-positive ASC-H compared with 27 of 266 patients (10.2%) with HPV-positive ASCUS (P < 0.0001) and 1 of 22 patients (4.5%) with HPV-negative ASC-H (P = 0.003); the latter result was similar to the finding of HSIL in 5 of 85 patients (5.9%) with HPV-negative ASCUS. The frequency of HPV-positive ASC-H in the current study (67%) was lower than that obtained in the ALTS for ASC-H (86%) but higher than that for ASCUS in both this study (45%) and in the ALTS (51% for all ASC; 63% for ASCUS, equivocal for LSIL). Underlying HSIL was detected in a similar percentage of patients with HPV-positive ASC-H in this study and in the ALTS (41%).

CONCLUSIONS

The greater frequency of HPV positivity and the significantly increased risk of underlying HSIL for ASC-H compared with ASCUS indicated that ASC-H category utilization and performance are appropriate in this routine clinical practice setting. The lower frequency of HPV positivity for ASC-H compared with the ALTS data and the similar low risk of HSIL in HPV-negative ASC-H and HPV-negative ASCUS indicate that HPV testing for triage of ASC-H in routine practice has the potential to reduce the number of women who are referred for colposcopy without an increased risk of failure to detect HSIL among HPV-negative women, similar to its triage role for ASCUS.

Prevalence and typing of HPV DNA by hybrid capture II in women with ASCUS, ASC-H, LSIL, and AGC on ThinPrep Pap tests

Testing for human papillomavirus (HPV) DNA is now a viable option for the management of women with atypical squamous cells of undetermined significance (ASCUS). The utility of reflexive HPV DNA testing for women with a cytologic diagnosis of atypical glandular cells-not otherwise specified (AGC-NOS), ASCUS subtypes, and low-grade squamous intraepithelial lesion (LSIL) has not been well established. In the present investigation, reflex Hybrid Capture II HPV DNA testing results were evaluated for HPV prevalence and type in 371 women with abnormal cytologic diagnoses of ASCUS-not otherwise specified (ASCUS-NOS), ASCUS-suspicious for low-grade squamous intraepithelial lesion (ASCUS-L), atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion (ASC-H), AGC-NOS, and LSIL on ThinPrep Pap tests. Positive high-risk HPV DNA was identified in 53.6% of the study samples, including ASCUS-NOS 40.2% ASCUS-L 71.4%, ASC-H 37.5%, LSIL 88.6%, and AGC-NOS 0%. We conclude that reflex HPV DNA testing appears to not be useful for colposcopy triage for cytologic diagnoses of LSIL or AGC-NOS.

Atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion: The practice experience of a hospital-based reference laboratory with this new Bethesda system diagnostic category

The 2001 Bethesda System diagnostic category of atypical squamous cells cannot exclude a high grade squamous intraepithelial lesion (ASC-H) was developed and implemented after many studies that proved its clinical relevance. In this study, we describe the practice experience of a hospital-based reference laboratory with this new diagnostic category. The anatomic pathology computer database was searched, and 414 Papanicolaou (Pap) smears signed out as ASC-H were discovered among 60,390 Pap smear accessions over a 17-month period of time. One hundred four cases had corresponding tissue specimens. Slides from all Pap smears and tissue specimens were reviewed, and five Pap smears were reclassified, leaving 99 study cases. In our laboratory, 88.9% of the study cases had either low or high grade dysplasia diagnosed on subsequent tissue specimens. The positive predictive value of ASC-H for histologically proven high-grade squamous intraepithelial lesions (HSIL's) was 40.4%. Of those having human papillomavirus (HPV) hybrid capture II testing, high-risk HPV types were detected in 73.9% of cases. The majority of study cases had less than 25 atypical cells. In two hysterectomy cases and three loop electrosurgical excession procedure (LEEP) conization cases, high-grade dysplasia was present as a single microscopic focus, suggesting that the paucity of atypical cells in ASC-H Pap smears may be secondary to small lesion sampling. Thirteen study patients were postmenopausal and 30.8% had low-grade dysplasia, and of these, 46.2% had high-grade dysplasia on subsequent tissue specimens. In conclusion, our practice experience with ASC-H is similar to that reported in the literature before the 2001 Bethesda System.

Effect of Bethesda 2001 on reporting of atypical squamous cells (ASC) with special emphasis on atypical squamous cells-cannot rule out high grade (ASC-H)

We compared the overall ASC rate and the outcomes for women with different categories of ASC before and after TBS 2001 to evaluate the impact of TBS 2001. Our laboratory reported ASC in four subcategories before TBS 2001; ASC, favor reactive (ASC-R), favor low-grade squamous intraepithelial lesion (SIL) (ASC-L), undetermined significance (ASC-US), and ASC-H. Since the implementation of TBS 2001, we have been reporting ASC as ASC-US and ASC-H. After TBS 2001, our ASC rate decreased from 6.2% to 4% (P < 0.0001). Before TBS 2001, ASC-R carried the same risk as ASC-US for underlying condyloma/CIN 1. Moreover, ASC-R was rarely associated with CIN 2 or 3. Before TBS 2001, ASC-H captured more low-grade (condyloma/CIN 1) and less high-grade (CIN 2, 3, and SCC) lesions compared to after TBS 2001. More women with ASC-H after TBS 2001 underwent colposcopy (80% vs. 71%, P < 0.05). Twenty-two percent of women with ASC-H required 2-4 colposcopies to identify the high-grade lesion. Our results confirm that consistent application of TBS 2001 terminology for ASC reduces the ASC rate, and better identifies women at high risk for CIN 2, 3, and SCC. In addition, ASC-H requires very close clinical follow-up as a significant percentage of women require more than one colposcopy to identify the high-grade lesion.

Women with low-grade abnormalities on Pap smear should be referred for colposcopy

AIM

To assess cytological, colposcopic and histological outcomes in women referred to a teaching hospital dysplasia clinic with low-grade changes on screening Pap smear.

METHODS

Analysis of a computerised database.

RESULTS

Repeating the Pap test was of little value. Fifteen percent of women with low-grade changes on the referral smear had biopsy proven high-grade change. There was little difference in biopsy proven high-grade change in women referred with an 'abnormal smear of uncertain significance' (23%) or 'an abnormal smear of uncertain significance-possible high-grade change' (24%).

CONCLUSIONS

Given these findings and the current medico-legal climate, immediate referral of women with low-grade changes on routine cytology is indicated, and seems a safer option than the more conservative approach of a repeat smear in 6 or 12 months. Further study of the usefulness of separating smears of uncertain significance into high-grade and low-grade categories is warranted. Consumer input into recommendations for management of Pap smear abnormalities is required.

Outcome after a cytological prediction of glandular abnormality

BACKGROUND

The National Health and Medical Research Council of Australia Guidelines for the Management of Women with Screen Detected Abnormalities are under review. The availability of population-based Australian data on the outcome after a cytology prediction of glandular abnormality was considered relevant to revising the recommended investigations for women with these abnormalities.

AIM

To describe the outcome of women with cytological predictions of glandular abnormalities of the cervix during 1999.

METHODS

A longitudinal study using data held by the Pap Test Registers of Australia.

RESULTS

Over a 24 month period, 70% (95% confidence interval (CI) 62-78%) of women whose cytology was reported as adenocarcinoma in situ (AIS) were confirmed as having high-grade disease. Among women whose cytology was reported as 'inconclusive: possible high-grade glandular disease', the proportion of women having high-grade disease was 25% (95% CI 20-30%). For cytology reports of minor non-specific change (MNSC) of glandular cells, the proportion of women having high-grade disease was 10% (95% CI 8-12%). Cancer was diagnosed in 16%, 5% and <1% of women with index cytology reports of AIS, inconclusive and MNSC, respectively.

CONCLUSIONS

These results can be used to inform an evidence-based approach to the investigation and management of abnormal glandular cytology reports. The results can also be used to better inform women about the significance of their abnormal cytology.

Clinicopathological significance of Borderline Nuclear Change - High Grade Dyskaryosis Not Excluded

During a recent discussion on classification of cervical cytology, the introduction of a 'Borderline Nuclear Change - High Grade Dyskaryosis Not Excluded' (BNCH) category was proposed. BNCH cases diagnosed prospectively were retrieved from laboratory records. Questionnaires were sent to referring practitioners regarding clinicopathological outcome. Cytopathological features resulting in the BNCH classification were recorded on slide review. A total of 103 reports on conventional cervical smears diagnosed as BNCH from 1999 to 2002 were retrieved, comprising 0.096% of 107 634 smears. Of 86/103 cases with clinical follow-up, CIN2 or worse was present in 30 (35%); 15 (17%) showed a borderline/low-grade abnormality and 41 (48%) were negative. No individual cytopathological feature was predictive of high-grade disease on follow-up. The yield of high-grade abnormalities on follow-up of BNCH supports the introduction of this terminology.

The significance of the Papanicolaou smear diagnosis of low-grade squamous intraepithelial lesion cannot exclude high-grade squamous intraepithelial lesion

BACKGROUND

Cervical cytologic specimens that show a low-grade squamous intraepithelial lesion (LSIL) occasionally contain a few cells that are suspicious for, but not diagnostic of, a high-grade squamous intraepithelial lesion (HSIL). In such cases, a diagnosis of LSIL cannot exclude HSIL is rendered. The objective of the current study was to assess the positive predictive value (PPV) for HSIL in follow-up cervical biopsies for these cases.

METHODS

One hundred forty-four women with a Papanicolaou (Pap) diagnosis of LSIL cannot exclude HSIL and their follow-up cervical biopsies were reviewed. Results were compared with a control group of 155 women with a Pap diagnosis of LSIL. A subset of biopsies was tested and typed for human papillomavirus (HPV) DNA by polymerase chain reaction amplification using consensus primers followed by restriction fragment length polymorphism analysis. HPVs were scored as low-risk or high-risk types.

RESULTS

Women with LSIL cannot exclude HSIL had a higher incidence of HSIL (PPV = 29%) on follow-up cervical biopsy than the control group (PPV = 15%, P < 0.01). In addition, SIL, indeterminate grade was diagnosed in 10% of cervical biopsies in the study group as compared with 4% in controls. Review of Pap smears from the study group showed that there were 3 types of cells suspicious for a high-grade lesion: atypical squamous metaplastic cells (62%), atypical keratinized cells (20%), and dysplastic cells of borderline nuclear-to-cytoplasm ratio (18%). HPV analysis confirmed the presence of high-risk HPV types in the study cases with high-grade cervical biopsies.

CONCLUSIONS

Women with a Pap diagnosis of LSIL cannot exclude HSIL appear to be more likely to harbor a high-grade lesion than those diagnosed with LSIL alone. Its use appears warranted. Women with this diagnosis merit appropriate clinical follow-up to exclude HSIL.

Atypical squamous cells: update on current concepts

Besides all the confusion and associated problems that the use of ASC has created, it has initiated substantial investigational interest that has resulted in a better understanding of squamous intraepithelial lesions and the biology of cervical neoplasia. Although the category of ASC has created, and will continue to create, controversy in the diagnostic and management fields, it allows the pathologist to convey uncertainty that may be the result of poor sampling or difficulty in interpretation of a case. It is a valuable tool that the cytopathologist can use to make it known that the Papanicolaou test has its limitations and may need and benefit, in some instances, from support from ancillary studies. Similar limitations are recognized in other areas of pathology and the use of immunohistochemistry or molecular studies is widely accepted as an aid to a more specific and definitive interpretation. The time for the Papanicolaou test to be considered similarly has arrived. HPV DNA testing may not be the perfect test for cervical cancer screening because of high prevalence of HPV infection in the general population; however, it is currently the best-studied ancillary test and has been proven to be cost-effective for the triage of Papanicolaou tests with equivocal squamous cells. It is important for the cytopathologist to have well-developed diagnostic skills in interpreting gynecologic preparations, and to classify cases as ASC only when deemed appropriate. Downgrading cytologic findings that are diagnostic of a squamous intraepithelial lesion to ASC with the hope of supporting it by an HPV test will only result in a devaluation of the Papanicolaou test. Such recourse may, however, be acceptable in specific situations, such as in patients who have complex histories, atypical clinical presentations, or during pregnancy. Quality assurance measures to closely monitor the ASC:SIL ratio and the rate of HPV positivity in ASC cases will be essential to ensure the appropriate use of this interpretive category. The coordination of the 2001 Bethesda and ASCCP consensus meetings resulted in the new subcategories of ASC-US and ASC-H, along with well-defined management strategies for these interpretations. This new and clinically relevant terminology should lead to a reduction in difficulties at the clinical level and a more uniform management of patients, unlike the situation following Bethesda 1991 where the gynecologist was faced with a new "diagnosis" without specific management recommendations. The standardization of reporting and clinical management will also allow more reliable evaluation of patient outcomes and cost analysis. The 2002 American Cancer Society guidelines did not make specific recommendations regarding HPV DNA testing for the triage of patients who have a cytology result of ASC-US [64]. The FDA approved the expanded use of HPV testing in conjunction with the Papanicolaou test for cervical cancer screening in March of 2003. The future is likely to bring additional testing modalities that may be more specific for detecting squamous lesions that are more likely to persist or progress to carcinoma, than the currently available HPV tests. In addition, looking to the more distant future, recently published data from HPV vaccine trials suggests that immunizing women who are negative for HPV-16 may eventually reduce the incidence of cervical cancer [65]. At the present, however, the most effective method to decrease the mortality of this disease process is to make sure that all women have access to, and receive, effective cervical cytologic screening.

The clinician's view: role of human papillomavirus testing in the American Society for Colposcopy and Cervical Pathology Guidelines for the management of abnormal cervical cytology and cervical cancer precursors

The American Society for Colposcopy and Cervical Pathology (ASCCP) National Consensus Conference for the Management of Women With Cervical Cytological Abnormalities and Cervical Cancer Precursors was held on the National Institutes of Health campus in Bethesda, Md, September 6-8, 2001. The conference was attended by 121 representatives from 29 national organizations interested in cervical cancer screening issues. For the first time, guidelines for the management of women with abnormal cervical cytology, developed from evidence-based literature, were presented to delegates from the majority of organizations with interest in cervical cancer screening, voted on, and revised when necessary to achieve a majority two-thirds approval. This development of consensus-approved guidelines is likely to be considered one of the most important milestones to date in the management of women with abnormal cervical cytology. The timing of this Consensus Conference resulted from the convergence of many different factors, including new cytologic terminology developed at the Bethesda 2001 workshop and publication of the enrollment data from the National Cancer Institute's Atypical Squamous Cells of Undetermined Significance (ASC-US)/Low-Grade Squamous Intraepithelial Lesions (LSIL) Triage Study, otherwise known as ALTS. Additionally, new preliminary longitudinal ALTS data provided much of the information on the natural history of abnormal Papanicolaou tests and cervical intraepithelial neoplasia (CIN), as well as data on the performance of both new liquid-based cytology and human papillomavirus (HPV) DNA testing in the management of women following colposcopy. The result was a large database of new information that provided the foundation for the ASCCP Consensus Conference. This article covers only the recommendations of the ASCCP Guidelines that were based in large part on the results of the ALTS trial. Therefore, the focus is on the management of women with equivocal (ASC-US) and low-grade (LSIL) cytologic abnormalities. Management of women with these cytologic abnormalities has been particularly problematic, because individually these women are at least risk for CIN 3 and cancer, yet their sheer numerical dominance ensures that they account for the majority of high-grade CIN detected in the United States in the follow-up of abnormal cervical cytology. Data from ALTS confirmed that women with ASC-US could be safely managed by any of the conventional approaches (repeat Papanicolaou test, immediate colposcopy, or HPV testing), but that the preferred management approach for women having an ASC-US report from liquid-based cytology was to assess the patient's risk by testing for HPV. Additionally, longitudinal ALTS data determined that repeat liquid-based cytology at 6 and 12 months and an HPV test at 12 months were nearly equivalent options in the follow-up of women referred for HPV-positive ASC or LSIL, yet not found to have CIN 2+ at initial colposcopy. Therefore, all follow-up recommendations for women with CIN 1 or lower postcolposcopy findings include these 2 options. The data and the recommendations for the management of ASC-US, ASC cannot exclude high-grade squamous intraepithelial lesion, and LSIL are discussed.

Reporting of atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion (ASC-H) on cervical samples: is it significant?

"Atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion (ASC-H)" is a new diagnostic category in the 2001 Bethesda nomenclature system for cervical cytology. The purpose of this 7-mo retrospective study (March 1, 2002-September 30, 2002) was to evaluate the significance of ASC-H on cervical Thin Prep Pap Tests. During this period, 25 (0.27%) of 9,214 Pap Tests were diagnosed as ASC-H, 22 of which resulted in either follow-up cervical biopsies and/or cervical cones, and which formed the basis of this study. Tissue specimens (22 cases) were negative in 5 cases (23%) and positive in 17 cases (77%). Of the positive specimens, there were 2 (12%) low-grade squamous intraepithelial lesions (LSIL) and 15 (88%) high-grade squamous intraepithelial lesions (HSIL). Of the 22 cases, ASC-H diagnoses included immature/atypical squamous metaplasia vs. a squamous intraepithelial lesion (SIL) in 19 (86%) cases, and tight clusters of small cells with a high nuclear to cytoplasmic ratio in 3 (14%) cases. The results of this study indicate that the reporting of ASC-H on cervical samples does lead to the detection of HSILs in a significant number of cases (68% in this study). Therefore, further evaluation of the patient is warranted.

Borderline nuclear change; can a subgroup be identified which is suspicious of high-grade cervical intraepithelial neoplasia, i e CIN 2 or worse?

Borderline nuclear change; can a subgroup be identified which is suspicious of high-grade cervical intraepithelial neoplasia, i.e. CIN 2 or worse? Only 10% of first borderline smears are associated with a histological high-grade (HG) abnormality, i.e. CIN 2,3, invasive malignancy or glandular neoplasia on subsequent investigation. The advantages of highlighting this subgroup are obvious but is this possible? From 1996 and 1997, 242 borderline smears with histological follow-up were examined by two independent experienced observers (observer 1 and 2) without prior knowledge of further investigation results. For each smear a profile of nuclear details was produced, also noting the type of cell mainly affected by the process; then the observers were asked to assess the degree of worry of HG disease for each smear i.e. whether the smear fell into group 1 borderline changes indicative of low-grade (normal, inflammatory, CIN1/HPV) disease (BL/LG) or group 2 difficult borderline smear, HG disease (CIN 2,3, invasive neoplasia or glandular neoplasia) cannot be excluded (BL/HG). Observer 1 selected a group of BL/HG with a PPV for HG disease of 38%, with observer 2 having a PPV of 50%; this compared with the overall laboratory HG disease PPV for borderline smears of 14%. Both observers found the most useful criterion to be the increase in nuclear:cytoplasmic ratio. Our results show that it is possible to separate a small group of borderline smears which should be classified as 'borderline/high grade lesion difficult to exclude' (BL/HG). Both observers had some success in arriving at this classification although their method of selecting out this group was quite different.

High grade abnormalities following an 'inconclusive' smear

OBJECTIVE

The National Health and Medical Research Council (NHMRC) recommends a report of 'inconclusive possible high grade epithelial abnormality', but many laboratories only report 'inconclusive' with reference to any possible high grade disease elsewhere in the report. This study was performed to determine possible reasons for cytological difficulties resulting in this category of report and to determine the rate of significant disease within this category.

DESIGN

Retrospective record review. Clinical details were extracted without patient-identifying data.

SETTING

Gynaecological Oncology Department, King George V/Royal Prince Alfred Hospital.

POPULATION

Two hundred patients referred with the cytological abnormality.

MATERIALS AND METHODS

An adequate colposcopic diagram documenting size, distribution and grade of lesion was required. All patients had colposcopy with management according to colposcopic and histological results as appropriate to their disease.

OUTCOME MEASURES

Colposcopic features, topography and size of any lesion, histological results, treatments performed and subsequent review of untreated patients.

RESULTS

Colposcopy found high-grade lesions in 43% and carcinoma in 1%. Histopathology found 49% and 4% respectively. Treatment was performed in 124 patients. Inflammation was found in 27%, a small lesion in 43% and endocervical disease in 21%.

CONCLUSIONS

The high rate of endocervical disease, inflammation and small lesions may explain the cytological difficulties leading to an 'inconclusive' result. The authors believe that the term 'inconclusive' alone does not adequately convey the high level of risk faced by these patients.

Qualification of ASCUS. A comparison of equivocal LSIL and equivocal HSIL cervical cytology in the ASCUS LSIL Triage Study

Cytologic detection of high-grade squamous intraepithelial lesions (HSILs) is critical to cervical cancer prevention. Therefore, identifying "equivocal HSIL" (ASCUS [atypical squamous cells of undetermined significance]-H) may be useful. Accordingly, we compared findings associated with "equivocal low-grade SIL" (ASCUS-L), ASCUS-H, and HSIL using data from the ASCUS LSIL (low-grade squamous intraepithelial lesion) Triage Study. The frequency of oncogenic human papillomavirus (HPV) DNA detection and underlying lesions cervical intraepithelial neoplasia (CIN) 2 or worse or CIN 3 or worse in women with ASCUS-H was intermediate between that of ASCUS-L and HSIL. Oncogenic HPV DNA was associated with 85.6% of ASCUS-H ThinPreps and 69.8% of ASCUS-H smears. Histopathologic lesions CIN 2 or worse were associated with 40.5% of ASCUS-H ThinPreps and 27.2% of ASCUS-H smears (mostly CIN 3). Nevertheless, numerically more lesions CIN 2 or worse were preceded by ASCUS-L than by ASCUS-H because ASCUS-L was more common. ASCUS-H is an uncommon interpretation that derives clinical usefulness from its high positive predictive value for lesions CIN 2 or worse.

Can glandular lesions be diagnosed in pap smear cytology?

Many reports have been published on the accuracy of the cervical vaginal smear for squamous lesions, and the literature contains fewer reports on the accuracy of the cervical vaginal smear for glandular lesions. The sensitivity of glandular lesion diagnosis depends on the subtype of lesion. The diagnostic sensitivity is highest for invasive endocervical adenocarcinoma and lowest for endometrial adenocarcinoma. The ability of some of the Bethesda system categories for glandular lesions to describe what they purport to describe is questionable. The Bethesda system categories of adenocarcinoma accurately classify adenocarcinomas. The Bethesda System category of atypical glandular cells of undetermined significance (AGUS) is a misnomer. Although many cases of adenocarcinoma in-situ are placed in this category, follow-up of patients with AGUS show that the majority of patients with clinically significant lesions have squamous dysplasias. Other categories of AGUS, such as AGUS favor endometrial origin, are more appropriately named and encompass endometrial lesions which are either neoplastic or non-neoplastic.