Cervical smear interpretations in women with a histologic diagnosis of severe dysplasia: factors associated with discrepant interpretations

Cytological features of human papillomavirus-infected immature squamous metaplastic cells from cervical intraepithelial neoplasia grade 2

In reflex cytology, the presence of prominent nucleoli in immature metaplastic squamous cells (IM) may be underdiagnosed due to variations in interpretation. The aim of this study is to identify human papillomaviruses (HPVs) that infect IM clusters in cervical intraepithelial neoplasia 2 (CIN2) on Papanicolaou (Pap) smears to determine the cytological features of lesion-derived cells. Thirty-two patients with a simultaneous diagnosis of CIN2 on biopsy and high-grade squamous intraepithelial lesions (HSIL) on cytology as well as with IM clusters on HSIL smears were included. CIN2 tissues and HSIL and IM clusters on Pap smears were isolated by manual microdissection, and HPV types were identified by PCR-based genotyping. The nuclear area within the IM clusters was also measured. The median nuclear area of HPV-negative IM clusters was 48 μm2 , with a coefficient of variation (CV) of 0.20; those of HPV-positive clusters were 66 μm2 and 0.34, respectively. The cut-off values of the nuclear area and CV for HPV positivity were 62 μm2 and 0.25, respectively. IM clusters composed of cells with a nuclear area of more than twice that of neutrophils or cells with a wide variation in nuclear sizes are likely to be neoplastic cells caused by HPV.

Cervical high-grade squamous intraepithelial lesion on conventional cytology: Cytological patterns, pitfalls, and diagnostic clues

BACKGROUND

Conventional cervical cytology, which has a relatively low sensitivity in diagnosing high-grade lesions as compared to liquid-based cytology, is still being practiced in low resource settings. This study aimed at elucidating various cytomorphological patterns, pitfalls, and subtle clues to high-grade squamous intraepithelial lesion (HSIL) diagnosis on conventional cervical cytology through cytologic-histologic correlation.

METHODS

Cervical biopsies reported as CIN2/3 were correlated with their corresponding Pap smears over a 10-year period to determine the frequency of undercalls. For characterization of overcalls, cervical smears reported as HSIL and their corresponding biopsies during the same period were correlated. The discordant cases in both the groups were reviewed for problematic patterns and pitfalls in cytological diagnosis of HSIL.

RESULTS

Of the 142 biopsies with CIN2/3, 29 (20.4%) cases had been undercalled on cytology. Sixteen (16) of these could be reclassified as ASC-H/HSIL on smear review. Smears showing predominant cells of low-grade squamous intraepithelial lesion grade with a few HSIL cells and those with small abnormal cells in an atrophic background formed the main confounders for HSIL underdiagnosis. Thirteen (13) out of 130 (10%) Pap smears called as HSIL, where biopsy diagnosis was less than CIN2, were labeled as overcalls. Atypical metaplasia, hyperchromatic crowded groups, and reparative changes constituted the major diagnostic pitfalls on cytology. A diligent smear review helped to reduce the undercall and overcall rates to 9.1% and 2.3%, respectively.

CONCLUSION

Awareness of morphological challenges in interpretation of HSIL among cytopathologists practicing cervical cytology would assist in reducing the diagnostic errors and ensure better patient management.

The association of a distinct plasma proteomic profile with the cervical high-grade squamous intraepithelial lesion of Uyghur women: a 2D liquid-phase chromatography/mass spectrometry study

OBJECTIVE

To identify plasma protein biomarkers of cervical high-grade squamous intraepithelial lesion (HSIL) of Uyghur women by proteomics approach.

METHODS

Plasma protein samples of Uyghur women with HSIL and chronic cervicitis were analyzed with 2D HPLC followed by detection of target proteins with Linear Trap Quadrupole Mass Spectrometer (LTQ MS/MS).

RESULTS

We detected three upregulated and one downregulated protein peaks representing protein constituents distinguishing HSIL from controls by 2D HPLC, identified 31 target proteins by LTQ MS/MS. Further confirmed analysis with online software IPA® 8.7 and ELISA assay showed APOA1 and mTOR as potential biomarkers.

CONCLUSIONS

A distinct plasma proteomic profile may be associated with HSIL of Uyghur women.

Cytopathic effects of human papillomavirus infection and the severity of cervical intraepithelial neoplasia : A frequency study

Cytopathic effects related to the human papillomavirus (HPV) infection are more frequently found in cervical intraepithelial neoplasia (CIN) 1; however, there are indications that at least half the histological diagnoses of CIN2 and CIN3 include koilocytosis areas. The objective of this study was to evaluate the frequency of the cytological criteria suggestive of HPV infection in the cervical smears of women with a histological diagnosis of CIN. One hundred and sixty-two women with abnormal cervical smears and a diagnosis of CIN confirmed by histopathology were selected, including 46 cases of CIN 1, 42 of CIN 2 and 74 cases of CIN 3. Koilocytosis was found in 63% of the smears from women with a histopathological diagnosis of CIN 1. This sign was observed in 26.2% and 25.7% of smears of women with a diagnosis of CIN 2 and CIN 3, respectively. Cytomegaly also was frequent in cervical smears of women with histopathological diagnosis of CIN 1 (71.8%). On the other hand, spindle cells and atypical metaplasia were more frequent in women with CIN 2 and CIN 3. Atypical parakeratosis showed similar frequency in all grades of CIN diagnosis. Koilocytois and cytomegaly were inversely correlated with the diagnosis of CIN2 or CIN 3, with OR values respectively of 0.30 (95%CI 0.13-0.68) and 0.26 (95%CI 0.11-0.58). The others signs analyzed did not show any significant association. Koilocitosis and cytomegaly can provides good reassurance that a patient with atypical cervical smear have CIN 1.

Preceding cervical cytology in women with high-grade squamous intraepithelial lesion

OBJECTIVE

To evaluate the preceding cervical cytology and factors leading to cytohistologic discrepancy in women with high-grade squamous intraepithelial lesion (HSIL) histology.

METHODS

The records of women who were found to have histologically confirmed HSIL without any associated invasive and glandular lesions, at Chiang Mai University Hospital between January 2005 and May 2009, were reviewed. Cytohistological discrepancy was defined as HSIL histology preceded by low-grade squamous intraepithelial lesion (LSIL) and atypical squamous cells of undetermined significance (ASC-US) smears.

RESULTS

The records of 436 HSIL cases were reviewed. The mean age of the women was 45.0 ± 9.3 years. The preceding smear abnormalities were as follows: 275 (63.1%) with HSIL; 50 (11.5%) with atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H); 40 (9.2%) with squamous cell carcinoma; 35 (8.0%) with LSIL; 32 (7.3%) with ASC-US; and 4 (0.9) with glandular abnormality smears. Overall, the rate of cytohistological discrepancy was 15.4% (95% CI 12.1-19.1%). The small size of HSIL and presence of coexisting LSIL are significant independent predictors for cytohistologic discrepancy.

CONCLUSION

Approximately 15% of HSIL cases are under-diagnosed by cytology. Significant factors leading to cytohistologic discrepancy are lesion size and the presence of coexisting LSIL.

Intermediate-grade squamous intraepithelial lesion may be a valid diagnostic/interpretive category

We undertook this study to assess the characteristics of smears with features intermediate between high-grade squamous intraepithelial lesion (HSIL) and low-grade squamous intraepithelial lesion (ISIL). We also wanted to determine how these smears correlate with high risk biopsy diagnosis and to compare this with the biopsy correlation of LSIL and HSIL. Seventy-four squamous intraepithelial lesion (SIL) smears were identified as intermediate-grade SIL smears taken at colposcopy in a 1 year period. They were correlated with concurrent colposcopically guided biopsies. Thirty-five percent of cases with intermediate-grade SIL smears had a biopsy diagnosis of moderate dysplasia or higher as compared with 12% for LSIL 74% for HSIL. This confirmed our hypothesis that intermediate-grade SIL smears have a rate of biopsy diagnosis of moderate dysplasia or higher intermediate to that of LSIL and HSIL.

Cytomorphologic analysis and histological correlation of high-grade squamous intraepithelial lesions in postmenopausal women

Atrophy-related epithelial changes often pose a diagnostic difficulty during the interpretation of postmenopausal smears. The objectives of this study are to identify the cytomorphologic features of HSIL, in Pap smears of postmenopausal Pap women, and to investigate the possible criteria that could lead to an inaccurate interpretation and false-positive results. Forty Pap smears that were reported as HSIL in postmenopausal women were reviewed. Follow-up cervical biopsies were available on all cases, of which 6 cases were immunostained for MIB-1 and P16. The following cytomorphologic features were evaluated: smear background, degree of cellularity, cellular arrangement, nuclear size, nuclear membrane irregularity, nuclear/cytoplasmic ratio, hyperchromasia, and chromatin pattern. Significant histological abnormalities were present in 35 out of 40 cases. Of those, 22 (55%) cases had high-grade cervical intraepithelial neoplasia (CIN2 or CIN3), 10 (25%) had CIN-1, 5 (12.5%) had reactive changes in the biopsy, and 3 cases had invasive squamous cell carcinoma. The cytomorphologic features that favored HSIL (P < 0.05) included: increased number of abnormal cells, nuclear membrane irregularities, cellular arrangement, and high nuclear/cytoplasmic ratio. Granular background, nuclear size, hyperchromasia, and abnormal chromatin pattern can be associated with reactive and atrophic changes. Our study showed that cytomorphological features favoring HSIL in postmenopausal smears include increased number of abnormal single cells with high nuclear/cytoplasmic ratio and irregular nuclear membrane. Granular background, nuclear enlargement, abnormal chromatin pattern, and hyperchromasia can be seen in reactive changes, and may lead to inaccurate interpretation.

Determinants of human papillomavirus-negative, low-grade squamous intraepithelial lesions in the atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesions triage study (ALTS)

BACKGROUND

Although low-grade squamous intraepithelial lesions (LSIL) most often are the result of infection by human papillomaviruses (HPV), a small proportion of women with LSIL have negative HPV tests. Using the Atypical Squamous Cells of Undetermined Significance/LSIL Triage Study (ALTS) population, the authors evaluated the significance of HPV-negative LSIL.

METHODS

Women with cytologic interpretations of LSIL by referral Papanicolaou (Pap) tests or enrollment ThinPrep tests (range, 1195-1476 women, depending on the specimen type and the reviewer) had HPV testing performed by both Hybrid Capture 2 and polymerase chain reaction (PCR)-based linear array for 27 HPV types.

RESULTS

Using 4 independent cytologic definitions of LSIL, only 3-11% of women with LSIL were found to have HPV-negative results on both HPV tests. The demographic characteristics of women with HPV-negative LSIL were consistent with those of a low-risk population; many were age > 35 years, and many reported no or only 1 recent sexual partner. The absolute risk of a histologic diagnosis of cervical intraepithelial neoplasia (CIN) Grade 3/carcinoma during the 2-year trial was lower for women with HPV-negative LSIL (range, 2-4%) compared with the absolute risks for oncogenic HPV-positive women with LSIL (range, 13-19%). However, at the next 6-month follow-up visit, 12%-32% of the women with HPV-negative LSIL had a positive HPV test. Finally, visual inspection of cervigrams demonstrated a clear association between a larger os and negative HPV test results compared with women who had HPV-positive LSIL. This may have influenced HPV sample adequacy.

CONCLUSIONS

Based on the ALTS data, the authors found no evidence to support the existence of HPV-negative LSIL as a distinct biologic entity related to the risk of cervical carcinoma. Such results appear to represent cytologic misinterpretations or falsely negative HPV tests.

Human papillomavirus oncogenic expression in the dysplastic portio; an investigation of biopsies from 190 cervical cones

In this study, we investigated the presence of E6/E7 transcripts of seven common high-risk human papillomavirus (HPV) types in 190 cervical biopsies. The RNA-based real-time nucleic acid sequence-based amplification assay (NASBA) and type-specific PCR, both detecting HPV 16, 18, 31, 33, 45, 52, and 58, as well as consensus PCR, were performed on all 190 biopsies. High accordance between type-specific and consensus PCR confirms that the HPV types included in this study are the most common types present in cervical dysplasia. Furthermore, we see a clear increase in the incidence of HPV, both DNA and RNA, along with the histological severity of dysplasia. HPV RNA was detected in all but two PCR-positive cases, confirming that the virus exerts E6/E7 mRNA expression in cases of high-grade dysplasia. Out of 19 women given a normal or borderline diagnosis at conisation, only four were found HPV positive, which may suggest that unnecessary conisations can possibly be reduced by introducing HPV testing into the preoperative routine assessment.

Significance of subclassifying high-grade squamous intraepithelial lesions into moderate dysplasia/CIN II versus severe dysplasia/CIN III/CIS in the Bethesda system terminology

Recent revisions of the Bethesda System (TBS III) did not modify the original two-tiered low-grade and high-grade squamous intraepithelial lesion (LSIL/HSIL) terminology and continued to offer the option of subclassifying HSIL into moderate dysplasia/cervical intraepithelial neoplasia (CIN II) and severe dysplasia/CIN III. The purpose of this study is to evaluate the significance of the HSIL moderate dysplasia/CIN II subclassification and the causes of Pap test-biopsy discordance for this subclassification. HSIL/moderate dysplasia/CIN II Pap tests were identified from the University of California Davis Medical Center laboratory file for a 5-yr period (1997-2001) and correlated with follow-up cervical biopsies. Cervical biopsies with CIN II diagnoses were identified from the laboratory file for the same time period, and correlated with their preceding Pap test. Discordant Pap test-biopsy pairs from either group were reviewed by two pathologists for the following causes for discordance: cytologic overcall or undercall, biopsy overcall or undercall, and sampling error or possible lesion regression. During the review period, 161 of 378 total HSIL Pap tests had a HSIL/CIN II result (42%), and 81/161 (50%) had a follow-up cervical biopsy. 38/81 (47%) were concordant, and 43 (53%) were discordant; 39/43 discordant cases had both Pap test and biopsy slides available for review. CIN I was the most common discordant biopsy diagnosis. Sampling error was the most common cause of discordance and was three times more common than the other causes; 536 CIN cervical biopsies with CIN were identified in the laboratory files during this review period, and 108/536 (20%) received a diagnosis of CIN II. Sixty-seven of 108 (62%) had a preceding Pap test result available; 32 of the 67 (48%) had a concordant preceding Pap test with a HSIL/CIN II result, and 35 (52%) were discordant; 32/35 discordant cases had both Pap test and biopsy slides available for review. LSIL was the most common discordant Pap test diagnosis. Sampling error was also the most common cause of discordance, and was also three time more frequent than any other cause for discordance. HSIL/CIN II is a meaningful subclassification in our laboratory. We support the TBS III recommendation for optional subclassification of HSIL and suggest that individual laboratories may wish to monitor use of this subclassification through internal correlation studies.