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

Comparison of the Hybrid Capture II Method with a PCR-Based Screening Method Using a Carboxyfluorescein-Labeled Primer for Detecting Human Papillomavirus in Cervicovaginal Liquid-Based Cytology

Objective: Human papillomaviruses (HPVs) are DNA viruses, of which over 120 types have been identified. The main screening methods for HPV-DNA include the hybrid capture II (HC-II) and polymerase chain reaction (PCR) assays. Liquid-based cytology (LBC) is a high-quality technique developed to improve the diagnostic reliability of traditional Papanicolaou tests (Pap tests). However, relatively few studies have compared the efficacy of PCR and HC-II assays using cervicovaginal LBC specimens. In this study, we conducted a comparative analysis with results derived from the HC-II assay to assess whether a PCR-based assay using a novel carboxyfluorescein (FAM)-labeled primer could be applied to cervicovaginal LBC specimens. Methods and Results: We analyzed 59 specimens diagnosed as atypical squamous cells of undetermined significance (ASCUS) by Pap tests. After extracting DNA from cervicovaginal LBC specimens, we performed PCR using a FAM-labeled consensus primer, and then conducted fragment analysis to confirm the results. The value of the kappa statistic measuring the agreement between the PCR and HC-II results was 0.8557, or “almost perfect agreement.” Conclusion: Our novel HPV-PCR assay can be successfully applied to cervicovaginal LBC specimens for the detection of HPV subtypes.

Challenges in the Pap diagnosis of endocervical adenocarcinoma in situ

INTRODUCTION

Recognition of adenocarcinoma in situ (AIS) in cervical cytology is challenging.

MATERIALS AND METHODS

We calculated the sensitivity and accuracy of Papanicolaou (Pap) tests obtained within 1 year of a histologic diagnosis of AIS from 2007 to 2016. We also correlated it with the coexistence of squamous lesions, calculated the interobserver agreement, and compared these measures with those of endocervical adenocarcinoma (ECCA). We correlated AIS detection with high-risk human papillomavirus (hrHPV) status.

RESULTS

Of 72 patients with histologic AIS and 48 patients with ECCA, 92% and 87.5%, respectively, had abnormal Pap test results. A glandular abnormality was detected in 44.4% of the AIS and 77.1% of the ECCA cases. Complete cytohistologic concordance was reached in 8.3% of AIS and 22.9% of ECCA cases. In addition, 27.8% of AIS and 6.3% of ECCA cases were diagnosed on Pap as a high-risk squamous abnormality. Concurrent squamous lesions were present in 79.2% of patients with AIS and 29.2% of patients with ECCA. The Paps from the AIS and ECCA cases were diagnosed as pure squamous abnormalities in 47.2% and 10.4% of cases, respectively. In the AIS cases, interobserver agreement was substantial for detection of any high-risk cytologic abnormality (kappa = 0.67) and fair for detection of any glandular abnormality (kappa = 0.34). Among the 26 patients with AIS tested for hrHPV, 92% had positive results and 8% had negative results.

CONCLUSIONS

The cytologic sensitivity for the detection of AIS remains low. It is directly related to the coexistence of squamous lesions. Cytology and hrHPV as stand-alone screening tests fail in the early detection of a small proportion of glandular lesions, although combined testing will improve their detection rates.

False-Negative Interpretation of Adenocarcinoma In Situ in the College of American Pathologists Gynecologic PAP Education Program

CONTEXT

- Adenocarcinoma in situ (AIS) is difficult to correctly interpret on Papanicolaou (Pap) cytology slides and false-negative interpretations of AIS can cause significant problems in daily practice.

OBJECTIVE

- To investigate the false-negative interpretation rate of AIS and the factors related to false-negative interpretation through responses in an educational environment.

DESIGN

- We retrospectively evaluated 11 337 responses in the PAP Education Program (PAP-Edu) from 173 AIS slides from 2011 to 2015. The false-negative interpretation rate, most common false-negative interpretations, and related other factors were evaluated.

RESULTS

- The overall false-negative rate was 6.9% (784 of 11 337). Respondents correctly interpreted AIS 50.0% (5667 of 11 337) of the time; high-grade intraepithelial lesion (HSIL) and malignancies (adenocarcinoma, squamous cell carcinoma, and other carcinomas) accounted for 42.7% (4842 of 11 337) and low-grade intraepithelial lesion accounted for 0.4% (44 of 11 337) of responses. Overall, 92.7% (10 509 of 11 337) of responses were HSIL and above. Among 784 false-negative responses, negative for intraepithelial lesion or malignancy was the most common (61.5% [482 of 784]), followed by reparative changes (24.1% [189 of 784]) and atrophic vaginitis (7.7% [60 of 784]). Overall, pathologists' responses showed a significantly higher false-negative rate than cytotechnologists' responses (8.3%, 403 of 4835 versus 5.7%, 275 of 4816; P < .001). The false-negative response rates were not statistically different among preparation types.

CONCLUSIONS

- The low correct interpretation rate and higher false-negative rate for AIS demonstrate the difficulty in interpreting AIS on Pap cytology, which may cause clinical consequences. The higher false-negative rate with pathologists than with cytotechnologists suggests cytotechnologists' higher screening sensitivity for AIS or cautious interpretation to avoid false-positive results by pathologists.

Detection of in situ and invasive endocervical adenocarcinoma on ThinPrep Pap Test: Morphologic analysis of false negative cases

Background:

The goal of this study was to calculate the sensitivity and false negative (FN) rate of ThinPrep Pap Test (TPPT) and carefully analyze missed cases for educational purposes.

Materials and Methods:

Patients with histologically proven adenocarcinoma in-situ (AIS) or invasive endocervical adenocarcinoma (EAC) over a 17-year-period (1998-2015) were identified. The TPPT immediately preceding the histological diagnosis of AIS/ECA was designated as index Pap (IP). Paps up to 122 months before histologic diagnosis of AIS/ECA were considered for this study. All available negative and unsatisfactory TPPT were re-reviewed.

Results:

There were 78 patients with histologically-proven AIS (56) or ECA (22) with 184 TPPTs, and 95 of these TPPTs were abnormal. Of the abnormal cases, 55.7% TPPTs were diagnosed as endocervical cell abnormality (atypical endocervical cells/AIS/ECA). Notably, 44.2% of abnormal TPPTs were diagnosed as squamous cell abnormality (atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesion/high grade squamous intraepithelial lesion). Including the diagnoses of squamous cell abnormality, the sensitivity of index TPPT for histologically-confirmed AIS/ECA was 88%. Eighty-eight of 184 TPPT, including 10 IP, were negative = 87, or unsatisfactory = 1. Forty-two of these slides were available for re-review. Upon review, 21 TPPT (50%) were confirmed negative and 21 TPPT (50%) were reclassified as abnormal = 20, or unsatisfactory = 1. Of the FN cases, the main difficulty in correct diagnosis was the presence of few diagnostic cell clusters which had less feathering, and consisted of smaller, rounder cells in small and tighter clusters, with nuclear overlap. In particular, nuclear overlap in three-dimensional groups precluded the accurate diagnosis. Rare FN cases showed squamous cell abnormality on re-review, and rare cases showed obscuring blood or inflammation.

Conclusion:

A significant proportion of AIS/EAC is discovered after Pap showing squamous cell abnormality. FN cases were most commonly related to nuclear overlap in tight three-dimensional clusters.

The effect of coexisting squamous cell lesions on prognosis in patients with cervical adenocarcinoma in situ

OBJECTIVE

The aim of this study was to assess the relative incidences of cervical adenocarcinoma in situ (AIS) and squamous cell carcinoma in situ (sCIS) and to determine the effect of coexisting squamous cell lesions on prognosis in patients with cervical AIS.

STUDY DESIGN

We performed a retrospective review of patients diagnosed with AIS or sCIS who underwent cervical conization at a University hospital between 2000 and 2011.

RESULTS

A total of 1184 patients with cervical carcinoma in situ were included. The ratio of sCIS to AIS was 16:1. Among 71 patients with AIS, AIS with coexisting squamous cell lesions and AIS alone were detected in 41 patients (58%) and 30 patients (42%), respectively. During the median follow-up of 57.1 months, 5 episodes of AIS recurrences and one episode of invasive recurrence occurred. The recurrence rate was significantly higher in patients with AIS alone than in patients with AIS and coexisting squamous cell lesions (17% versus 2%; P=0.043).

CONCLUSION

These results suggest that patients with cervical AIS and coexisting squamous cell lesions have a more favorable prognosis than patients with AIS alone.

Multimodal entity coreference for cervical dysplasia diagnosis

Cervical cancer is the second most common type of cancer for women. Existing screening programs for cervical cancer, such as Pap Smear, suffer from low sensitivity. Thus, many patients who are ill are not detected in the screening process. Using images of the cervix as an aid in cervical cancer screening has the potential to greatly improve sensitivity, and can be especially useful in resource-poor regions of the world. In this paper, we develop a data-driven computer algorithm for interpreting cervical images based on color and texture. We are able to obtain 74% sensitivity and 90% specificity when differentiating high-grade cervical lesions from low-grade lesions and normal tissue. On the same dataset, using Pap tests alone yields a sensitivity of 37% and specificity of 96%, and using HPV test alone gives a 57% sensitivity and 93% specificity. Furthermore, we develop a comprehensive algorithmic framework based on Multimodal Entity Coreference for combining various tests to perform disease classification and diagnosis. When integrating multiple tests, we adopt information gain and gradient-based approaches for learning the relative weights of different tests. In our evaluation, we present a novel algorithm that integrates cervical images, Pap, HPV, and patient age, which yields 83.21% sensitivity and 94.79% specificity, a statistically significant improvement over using any single source of information alone.

Potential effects of updated pap test screening guidelines and adenocarcinoma in situ of the cervix

OBJECTIVE

To review cases of adenocarcinoma in situ (AIS) at our institution to examine how updated guidelines affect the timing of diagnosis.

METHODS

We identified patients with AIS diagnosed between 1998 and 2010 using the International Classification of Diseases, 9 Revision, Clinical Modification, code 233.1. Diagnosis was confirmed by pathology review. We abstracted demographic data, dysplasia history, and modalities utilized for diagnosis and treatment.

RESULTS

We identified 242 patients who met selection criteria. Two hundred eight (86%) had Pap test abnormalities at presentation. One hundred thirty-seven out of 208 (66%) patients with abnormal Pap test results had a squamous, rather than glandular, abnormality. The mean time from abnormal Pap test to diagnosis of AIS was 29 months in patients older than 30 years and was 21 months in patients 30 years or younger. In patients younger than 21 years, 16 out of 17 had abnormal screening Pap test results showing squamous lesions. Their subsequent treatment for squamous dysplasia ultimately led to the diagnosis of AIS.

CONCLUSION

: Updated screening guidelines may prevent the expeditious diagnosis of AIS in females younger than 21 years and those aged 21-29 years, many of whom had normal Pap test results within 3 years of diagnosis.

LEVEL OF EVIDENCE

II.

Associations between oral HPV16 infection and cytopathology: evaluation of an oropharyngeal "pap-test equivalent" in high-risk populations

Human papillomavirus (HPV) is responsible for the rising incidence of oropharyngeal squamous cell cancers (OSCC) in the United States, and yet, no screening strategies have been evaluated. Secondary prevention by means of HPV detection and cervical cytology has led to a decline in cervical cancer incidence in the United States. Here, we explored an analogous strategy by evaluating associations between HPV16 infection, cytopathology, and histopathology in two populations at elevated risk for OSCCs. In the first, a cross-sectional study population (PAP1), cytology specimens were collected by means of brush biopsy from patients presenting with oropharyngeal abnormalities. In the second (PAP2), a nested case-control study, bilateral tonsillar cytology samples were collected at 12-month intervals from HIV-infected individuals. The presence of cytopathologic abnormality in HPV16-positive tonsil brush biopsies (cases) was compared with HPV16-negative samples (controls) matched on age and gender. HPV16 was detected in samples by consensus primer PCR and/or type-specific PCR. Univariate logistic regression was used to evaluate associations. In PAP1, HPV16 alone (OR: 6.1, 95% CI: 1.6-22.7) or in combination with abnormal cytology (OR: 20, 95% CI: 4.2-95.4) was associated with OSCC. In PAP2, 4.7% (72 of 1,524) of tonsillar cytology specimens from HIV-infected individuals without oropharyngeal abnormalities were HPV16 positive. Tonsillar HPV16 infection was not associated with atypical squamous cells of unknown significance (ASCUS), the only cytologic abnormality identified. Therefore, HPV16 was associated with OSCCs among individuals with accessible oropharyngeal lesions but not with cytologic evidence of dysplasia among high-risk individuals without such lesions. An oropharyngeal Pap-test equivalent may not be feasible, likely due to limitations in sampling the relevant tonsillar crypt epithelium.