Atypical glandular cells of undetermined significance in conventional cervical/vaginal smears and thin-layer preparations

Atypical glandular cells and predictive features of malignancy in Pap smears: A retrospective monocentric study

OBJECTIVE

The introduction of cytological screening with the Papanicolau smear significantly reduced cervical cancer mortality. However, Pap smear examination can be challenging, being based on the observer ability to decode different cytological and architectural features. This study aims to evaluate the malignancy rate of AGC (atypical glandular cells) category, investigating the relationships between cytological and histological diagnosis.

METHODS

Eighty-nine patients, diagnosed as AGC at cytological evaluation and followed up with biopsy or surgical procedure at Policlinico Gemelli Hospital, Rome, Italy, were included in the study. The cytopathological architectural (feathering, rosette formation, overlapping, loss of polarity, papillary formation, three-dimensional formation) and nuclear (N/C ratio, nuclear enlargement and hyperchromasia, mitoses, nuclei irregularity, evident nucleoli) features of AGC were evaluated. Statistical analyses were performed to assess cyto-histological correlation and determine the relevance of architectural and nuclear features in the diagnosis of malignancy.

RESULTS

Of the 89 AGC patients, 48 cases (53.93%) were diagnosed as AGC-NOS and 41 (46.07%) were diagnosed as AGC-FN, according to the Bethesda classification system. The follow-up biopsies or surgical resections revealed malignancy in 46 patients (51.69%). The rates of malignancy for AGC-NOS and AGC-FN were 35.41% and 70.73% respectively. Furthermore, analysing cytopathological features, we found that both architectural and nuclear criteria were statistically significant (p < 0.05). Only overlapping, nuclear irregularity and increased N/C ratio were not found to be statistically significant for detecting malignancy.

CONCLUSIONS

Cytological diagnosis of glandular lesions remains a valid tool, when appropriate clinical correlation and expert evaluation are available.

Atypical glandular cells in Papanicolaou test: Which is more important in the detection of malignancy, architectural or nuclear features?

OBJECTIVE

Atypical glandular cells (AGCs) in Pap (Papanicolaou) smears are uncommon but may represent various benign and malignant lesions. The aim of this study was to evaluate the AGC incidence in Pap smears, analyse the relationship between AGC and malignancy, and reveal the importance of architectural and nuclear features observed cytologically in malignancies.

METHODS

Patients diagnosed with AGC on the basis of cervicovaginal cytology between May 2011 and July 2018 were included in this study. All slides were retrospectively reviewed and subclassified according to the Bethesda 2001 classification system. The cytomorphological features observed in the smears were recorded. Cytohistological correlations were evaluated, and the significant clinicopathological findings for malignancy were determined.

RESULTS

Of 87 536 Pap smears, 195 (0.22%) had AGC results and 156 had tissue follow-up. Among the 156 smears with AGC, 80 (51.3%) were diagnosed as AGC-NOS (atypical glandular cells, not otherwise specified) and 76 (48.7%) as AGC-FN (atypical glandular cells, favour neoplastic). Follow-up biopsies revealed benign pathologies in 49 cases (31.4%) and malignant pathologies in 107 (68.6%). The rate of malignancy observed in AGC-FN cases (89.5%) was higher than the rate of malignancy in AGC-NOS cases (48.8%). Among the cytomorphological features, nuclear irregularity, presence of macronucleoli, feathering, loss of polarity, papillary pattern, and three-dimensional formation were found to be significant indicators of malignancy.

CONCLUSION

As AGC in Pap smear was associated with a clinically significant diagnosis in 68.6% of the cases in our study, we suggest that all patients with AGC should undergo further clinical assessment.

Detection of transformation zone cells in liquid-based cytology and its comparison with conventional smears

BACKGROUND

To compare the differences between liquid-based cytology (LBC) and conventional cytology in respect of the detection of transformation zone cells (TZC) by age group and to assess test performance by correlating results with cytological abnormalities.

METHODS

A retrospective study assessing the results of cervical-vaginal cytology smears collected at a private laboratory in São Paulo (Brazil) between January 2010 and December 2015.

RESULTS

A total of 1 030 482 cytology tests were performed; of these, 3811 (0.36%) unsatisfactory samples were excluded. Cytology sampling in the patients studied was performed using the conventional technique in 394 879 (38.5%) cases and the liquid-based techniques in 631 792 (61.5%) cases. The proportion of samples with TZC for interpretation was 73.2% (288 956 samples) in conventional cytology and 52.7% (333 115 samples) in LBC (P < .001). The presence of TZC rate declined in both groups with age, but was consistently lower for LBC (P < .001). The presence of endocervical and metaplastic cells was associated with higher high-grade intraepithelial lesion detection rates.

CONCLUSION

Low representation of the transformation zone was found in the samples collected using the LBC technique, particularly in the over 50 age group. Conventional cytology was associated with a higher rate of detection of high-grade lesions.

Glandular Cell Abnormalities on SurePath Preparations: A Retrospective Review with Cytology-Histology Correlations

OBJECTIVE

Detecting glandular lesions is challenging by all Pap test methodologies. As the availability of data on identifying glandular abnormalities by SurePath is scarce, we investigated the detection rates and the correlation with histology follow-up.

STUDY DESIGN

A total of 105,927 cases (SurePath and conventional) were searched for the diagnosis of atypical glandular cells or higher glandular abnormalities (AGC+) with the corresponding histologic diagnosis. The associations between the Pap test methods and diagnostic categories were assessed by χ2 test.

RESULTS

Overall, 0.32% of SurePath (159/49,375) and 0.29% of conventional (164/56,552) cases showed AGC+ (p = 0.38). Histology confirmed significant abnormalities in 42 versus 53.5% of the cases, respectively (p = 0.064); 72.7% (SurePath) versus 65.2% (conventional) of these were glandular in nature (p = 0.37). The diagnosis of neoplasia (favored or definitive) showed malignancy on follow-up in 100% of SurePath cases (12/12). In contrast, 82.1% of these conventional cases disclosed premalignant or malignant lesions by histology (p = 0.12).

CONCLUSIONS

AGC+ cases showed higher prevalence on SurePath preparations. Conventional cases had more abnormalities on follow-up, while glandular lesions represented a higher proportion of abnormal histologies following SurePath AGC+s. The positive predictive value of favored or definite neoplasia was higher in SurePath cases. Overall, these differences were not statistically significant.

American cancer society guideline for the early detection of cervical neoplasia and cancer

An update to the American Cancer Society (ACS) guideline regarding screening for the early detection of cervical neoplasia and cancer, based on recommendations from a formal review and recent workshop, is presented. The new screening recommendations address when to begin screening, when screening may be discontinued, whether to screen women who have had a hysterectomy, appropriate screening intervals, and new screening technologies, including liquid-based cytology and HPV DNA testing.

Gynecologic cytology on conventional and liquid-based preparations: a comprehensive review of similarities and differences

Liquid-based preparations (LBPs) have largely replaced conventional Papanicolaou smears (CPS) for cervical samples in the United States and in many other industrialized countries. The two FDA-approved LBP currently in use include ThinPrep (TP), (Hologic Inc., Bedford, MA) and SurePath (SP), (BD Diagnostic, Burlington, NC). Split-sample and direct-to-vial studies have shown that LBPs show an overall improvement in sample collection and processing, reduce artifacts that interfere in diagnosis, are more sensitive, can be utilized for ancillary tests and are a cost-effective replacement for CPS. Comparative analyses of diagnostic accuracy indicate that LBPs perform at least as well as CPS. However, the added advantages of standardized, automated preparations and screening, reduced unsatisfactory rate, improved specimen adequacy and ability to perform human papillomavirus (HPV) test, are enough to continue use of LBP. The cytologic features in LBP are similar to CPS with subtle differences, particularly in background information. There are also subtle differences between the two LBPs, SP and TP, which are reflective of different sampling devices, collection media, and processing techniques. Architecturally, LBP shows smaller cell clusters and sheets and more dyscohesion. Cytologically, enhanced nuclear features and smaller cell size are more prominent. Advances in liquid-based Papanicolaou's (Pap) test have lead to well-defined patient management guidelines by the American Society for Colposcopy and Cervical Pathology. Herein, we review these aspects of Pap test including, morphology, automation, ancillary tests (HPV and immunochemistry), pertinent QA/QC monitors, patient management guidelines, and review of pertinent literature.

Atypical glandular cells (AGC): ThinPrep Imaging System (TIS), manual screening (MS), and correlation with Hybrid Capture 2 (HC2) HPV DNA testing

OBJECTIVE

The aim of the study was to determine if the ThinPrep Imaging System (T1S) improves the positive predictive value (PPV) of atypical glandular cell (AGC) diagnosis for identifying HPV-related squamous and/or glandular lesions over manual screening (MS), and if human papilloma virus (HPV)-DNA testing improves the diagnostic yield.

MATERIALS AND METHODS

85 ThinPrep cervical cytology specimens with a diagnosis of AGC by TIS (n = 51) and MS (n = 34) were retrieved. The diagnoses were correlated with corresponding histologic follow-up and high risk (HR)-HPV testing results.

RESULTS

The PPV of AGC by TIS and MS for HPV-related squamous lesions were similar. In the MS group, more cases of glandular pathology were identified, however only three represented adenocarcinoma in-situ (AIS), and the remaining ten were endometrial carcinomas (EMCA).

CONCLUSIONS

TIS and MS are comparable in the detection of AGC representing squamous histology and the addition of HPV DNA testing does not differentially improve performance. Although the MS group harbored more glandular pathology, the differences in the detection of AIS were not statistically significant.

Carbonic anhydrase IX and human papillomavirus as diagnostic biomarkers of cervical dysplasia/neoplasia in women with a cytologic diagnosis of atypical glandular cells: a Gynecologic Oncology Group study in United States

High-risk human papillomavirus (H-HPV) infection is strongly linked to cervical neoplasia, but its role in detecting glandular lesions (GLs) is unclear. In the cervix, carbonic anhydrase IX (CA-IX) is expressed in cervical neoplasia, but rarely in the benign cervix. The diagnostic utility of these biomarkers was evaluated in women with a cytologic diagnosis of atypical glandular cells (AGC). H-HPV was detected using hybrid capture 2 (HC2) in liquid-based cytology, and CA-IX immunoreactivity was studied on conventional Pap smears. Of 403 patients, 111 (28%) were positive for significant cervical lesions (SCLs) including CIN2, CIN3, adenocarcinoma in situ or invasive carcinoma. CA-IX testing alone (n = 403) had a sensitivity of 75, 95 or 65% for SCLs, significant GLs or squamous lesions (SLs), respectively, with a specificity of 88% and a false negative rate (FNR defined as 1 minus negative predictive value) of 10%. Testing for H-HPV (n = 122) had a sensitivity of 97, 100 or 96% for SCLs, GLs or SLs, respectively, with a specificity of 87% and a FNR of 1%. The combination of CA-IX and H-HPV testing (n = 122), collectively, had the same sensitivity, specificity and FNR for SCLs, GLs or SLs as H-HPV testing alone. The conclusions of our study are that both H-HPV and CA-IX testing are useful diagnostic markers for GLs. However, H-HPV testing is a better diagnostic marker for SLs. The combination of CA-IX with H-HPV testing does not improve the diagnostic accuracy for cervical neoplasia in women with AGC diagnosis over that of H-HPV testing alone.

Cervical cytology specimen adequacy: patient management guidelines and optimizing specimen collection

OBJECTIVE

To provide updated management guidelines according to cervical cytology specimen adequacy and techniques to optimize adequacy based on literature review and expert opinion.

MATERIALS AND METHODS

Selected members of the American Society for Colposcopy and Cervical Pathology committee and invited experts conducted a literature review and discussed appropriate management and areas for future research emphasis.

RESULTS

The guidelines recommend a repeat Pap test in a short interval of 2 to 4 months for most women when the cytology result is unsatisfactory. The preferred follow-up for women with a negative cytology result lacking an endocervical/transformation zone component or showing other quality indicators is a repeat Pap test in 12 months. Indications for an early repeat Pap test in 6 months are provided, and the influence of human papillomavirus testing results on management is discussed. Techniques for optimizing specimen adequacy are provided in detail.

CONCLUSION

The specimen adequacy management guidelines will help promote uniform and optimal follow-up of patients receiving cervical cytology screening. The topics for future research emphasis will be helpful in promoting studies in needed areas.

Comparative sensitivities of ThinPrep and Papanicolaou smear for adenocarcinoma in situ (AIS) and combined AIS/high-grade squamous intraepithelial lesion (HSIL): comparison with HSIL

BACKGROUND

Despite the historic belief that cytologic screening offers little protection against cervical adenocarcinoma (CAC), there is emerging evidence that, by detecting the precursor lesion, adenocarcinoma in situ (AIS), cervical screening may reduce the incidence of CAC as it has for cervical squamous carcinoma. Because liquid-based cytology is fast replacing the conventional Papanicolaou smear (PS), it is important to establish that it is at least as effective in detecting AIS.

METHODS

The authors calculated the sensitivities of PS and ThinPrep (TP) for 100 women with histologic AIS (from 160 PS slides and 60 TP slides), for 94 women with AIS+high-grade squamous intraepithelial lesion (HSIL) (from 151 PS slides and 50 TP slides), and for 558 women with HSIL (from 788 PS slides and 383 TP slides). All smears were taken up to 36 months before the histologic diagnosis.

RESULTS

In no category was there a significant difference between PS sensitivity and TP sensitivity. The HSIL category had a significantly higher overall sensitivity than the other categories. However, when sensitivity was defined as cytologic detection of high-grade disease, there was no difference between any of the categories. For the detection of a high-grade glandular lesion, the presence of a concurrent histologic HSIL was associated with reduced sensitivity for the detection of AIS.

CONCLUSIONS

The current results indicated that it may prove possible for cervical screening, with either PS or TP, to reduce the incidence of CAC.

Clinical significance of atypical glandular cells on cervical cytology

OBJECTIVE

To evaluate the prevalence and histologic outcomes of patients with atypical glandular cells of undetermined significance (AGUS), diagnosed by Pap test, and concurrent risk factors.

DATA SOURCES

A PubMed/MEDLINE/Ovid HealthStar search of the English literature was conducted from January 1988 through March 2004.

METHODS OF STUDY SELECTION

The search criteria included the terms "atypical glandular cells of undetermined significance," "AGUS," or "AGC." All studies investigating the clinical significance of patients with an AGUS Pap test were included, except for those where consecutive Pap tests were not studied. Diagnostic outcomes were then determined.

TABULATION, INTEGRATION, AND RESULTS

Of the 916 studies identified, 24 met our inclusion criteria. Of the 2,389,206 Pap tests included in these studies, 6,829 (0.29%) had AGUS. Follow-up was available for 3,890 tests. These data showed the following rates of pathology: 8.5% low-grade squamous intraepithelial lesions (LSIL), 11.1% high-grade squamous intraepithelial lesions (HSIL), 2.9% adenocarcinoma in situ, 1.4% endometrial hyperplasia, and 5.2% malignancy. The most common malignancies were endometrial adenocarcinoma (57.6%), cervical adenocarcinoma (23.6%), ovarian and fallopian tube carcinoma (6.4%), squamous cell carcinoma of the cervix (5.4%), and other (6.9%). Of the AGUS Pap tests, the remaining 71.0% corresponded to benign findings, including reactive changes, polyps, and normal histology. Patients with AGUS, which favors a neoplastic process, or with a concurrent ASCUS have a greater likelihood of disease.

CONCLUSION

Histologic diagnosis showed that 29.0% of these Pap tests had findings requiring follow-up or therapeutic intervention, including a 5.2% rate of malignancy. Based on these findings, 99.6% of the diagnoses are within the region of surveillance when AGUS Pap tests are evaluated with colposcopy and directed biopsy, endocervical curettage, an endometrial biopsy in patients with risk factors for endometrial cancer, and pelvic examination.

Accuracy of diagnosis of atypical glandular cells—Conventional and ThinPrep

The incidence of glandular cervical malignancy is steadily increasing. Glandular abnormalities are more frequently diagnosed on cervical smears. In this study, we attempt to evaluate our experience with glandular cytology and to assess the sensitivity and specificity of the ThinPrep (TP) over conventional Papanicolaou (Pap) smears. Glandular abnormalities during a 3-yr period from October 2000 to October 2003 were retrieved from our cytology database. The study group comprised smears from 369 patients, 272 conventional Pap smears (CPSs) and 97 TP from a total of 400,184 smears. The types of glandular abnormalities were tabulated following a modified Bethesda classification. Correlation with histology and follow-up cytology was achieved in all but six patients. Significant lesions were identified in 116/272 (PPV 42.6%) of CPSs and 58/97 (PPV 58.9%) TPs. Pure glandular abnormalities numbered 125 conventional and 51 TP; significant lesions identified in this group were 36/125 (PPV 28.8%) CPS and 26/51 (PPV 50.9%) TP. Statistical analysis showed significant differences for positive predictive values of TP and CPS and a suggestion of increased sensitivity. The main limiting factor was small numbers of glandular abnormalities and a desirable longer study time.

Chapter 11: Future directions in cervical pathology

Technologic innovations, including the development of improved sampling devices, liquid-based collection systems, and computer-assisted screening, have revolutionized cervical cytology. Biologic discoveries in upcoming years promise to transform our understanding of the pathogenesis of cervical neoplasia, leading to another quantum leap in our approach to screening and prevention. This review summarizes the opportunities and challenges that recent and anticipated advances in pathology present for epidemiologic research.

Atypical glandular cells?an update

The diagnostic category of atypical glandular cells (AGC) in the Bethesda system for the reporting of cervicovaginal cytology has undergone significant modification since its inception in 1988. More than a decade later, this category remains a diagnostic challenge to both clinicians and cytopathologists because of the lack of uniform cytologic criteria, the lack of interobserver agreement in the diagnosis, and the lack of standardized patient management guidelines. This article reviews the current classification of AGC in the Bethesda system, the cytomorphologic features and differential diagnosis, the clinical significance of a diagnosis of AGC, and the clinical management of patients with AGC. This article provides a comprehensive clinicopathologic review of the category of AGC.

Atypical glandular cells

The 2001 Bethesda System has radically altered the classification of glandular abnormalities. The recognition of the cytologic features of atypical glandular cells on cervicovaginal smears is important because a significant number of patients will be found to have an underlying cancerous or dysplastic lesion of the exocervix, endocervix, or endometrium. The differential diagnosis of AGC on cytology is diverse and accurate classification is necessary because the most appropriate form of follow-up depends on the specific subcategorization of the atypical glandular cells. Because the level of interobserver agreement in the diagnosis of AGC is poor, effective communication between cytopathologists and clinicians is essential to accurately triage these patients. This article should help the cytology practitioner by providing a comprehensive review of the approach to the interpretation, clinical significance, histopathologic correlation, and management of patients who have atypical glandular cells on gynecologic cytology specimens.

Predictive value of diagnoses of endocervical glandular abnormalities in cervical smears

AIMS

To determine the positive predictive value (PPV) of cervical smear diagnoses of 'definite' and 'possible' endocervical adenocarcinoma in situ or invasive adenocarcinoma, and whether diagnostic accuracy can be improved.

METHODS

The study examined cervical smears reported as definite or possible high-grade glandular abnormality between 1992 and 1998. PPV was calculated by comparing smear diagnoses with the subsequent histopathology report. All available smears were reviewed without knowledge of follow-up results, and were reclassified by consensus.

RESULTS

Thirty-two smears were diagnosed as high-grade glandular lesions, with adequate biopsy follow-up in 31 cases (96.9%). A high-grade epithelial abnormality (HGEA) was detected in 29 cases (PPV, 93.5%), with a high-grade glandular lesion in 24 (PPV, 77.4%). Very few smears were reclassified on review. Seventy-three smears were initially diagnosed in the 'inconclusive' glandular or indeterminate cell-type category. There was adequate biopsy follow up for 54 cases (74.0%). On follow-up, 31 cases had a HGEA (PPV, 57.4%), with 14 cases having a high-grade glandular abnormality (PPV, 25.9%). In the review of 'inconclusive' smears, 12 were reclassified as squamous abnormalities and none of these had a glandular lesion on biopsy. Eight were reclassified as negative; seven contained endometrial stroma and the glandular cells in question were considered to be of lower uterine segment (LUS) origin. No significant lesion was present on follow-up of these cases.

CONCLUSIONS

For clinicians using our laboratory, large loop excision of the transformation zone (LLETZ) or cone biopsy should follow a 'definite' cytological diagnosis of a high-grade endocervical glandular lesion. However, cone biopsy may not be the appropriate initial management in the 'possible' high-grade glandular group because of a significantly lower predictive value of the diagnosis. The slide review highlighted the importance of (1) caution in classifying sheets of abnormal cells as glandular, and (2) endometrial stroma as a marker of LUS material.