Colposcopic Findings and Diagnosis in Low-Income Brazilian Women with ASC-H pap Smear Results

OBJECTIVE

 To determine the accuracy of colposcopy findings in diagnosing cervical intraepithelial neoplasia (CIN) in women with an atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H) pap smear result and analyze whether the prevalence of HSIL and cancer correlates with sociodemographic risk factors and specific colposcopic findings.

METHODS

 Colposcopic findings and sociodemographic risk factors were analyzed as possible predictors of a CIN 2 or worse diagnosis in women with an ASC-H pap smear result.

RESULTS

 Accuracy of the colposcopic impression was 92%, sensitivity was 91.6%, and specificity was 93.1%, with a positive predictive value of 96.4% and negative predictive value of 84.3%. Diagnosis of CIN 2 or worse was more frequent in patients with a previous history of cervical dysplasia and pre-menopausal patients. Identification of major colposcopic findings, dense acetowhite epithelium, coarse mosaicism, and punctuation correlated significantly with CIN 2 or worse.

CONCLUSION

 Colposcopy performed by an experienced examiner can accurately differentiate patients with CIN 1 or less from patients with CIN 2 or worse. Diagnosis of CIN 2 or worse was more frequent in patients with a previous history of cervical dysplasia and pre-menopausal patients. The degree of acetowhite changes was the best colposcopic feature to predict CIN2 or worse.

Practical usefulness of atypical endometrial cell categories within the new classification of endometrial cytology when applied to conventional smears

OBJECTIVE

Endometrial cytology has been widely used as a screening tool in Japan. Traditionally, a three-tier reporting system, consisting of 'negative', 'suspicious' and 'positive' categories, has been used. However, a more descriptive system, the New Terminology in Endometrial Cytology (NTEMC), which is based on the Bethesda System for uterine cervical cytology, was introduced recently. The objective of this study was to validate the NTEMC criteria.

METHODS

Endometrial cytology specimens that had been categorised as 'suspicious' were collected in our hospital between 2003 and 2013, and from these, 106 specimens with corresponding histological results, were re-evaluated according to the NTEMC criteria. Diagnostic categories were assigned based on that chosen by the majority of the examining members.

RESULTS

Negative, atypical endometrial cells, of undetermined significance (ATEC-US), atypical endometrial cells for which atypical endometrial hyperplasia or worse cannot be excluded (ATEC-A), endometrial hyperplasia, atypical endometrial hyperplasia and malignancy were selected as the diagnostic categories for 9 (8.5%), 34 (32.1%), 17 (16%), 34 (32.1%), 5 (4.7%) and 7 (6.6%) specimens, respectively. Corresponding histological categories of benign, endometrial hyperplasia, atypical endometrial hyperplasia and malignancy were established in 28 (82.4%), 1 (2.9%), 2 (5.9%) and 3 (8.8%) ATEC-US specimens, respectively, and in 6 (35.3%), 3 (17.6%), 2 (11.8%) and 6 (35.3%) ATEC-A specimens, respectively. The histological category distribution differed significantly (P = 0.001), and there was a significant correlation between corresponding cytological and histological categories (P = 0.005).

CONCLUSION

The ATEC category of NTEMC system works well in a practical setting and resembles the Bethesda reporting system ASC (atypical squamous cells) category for cervical cytology.

Clinical Relevance of ASC-H Cytologies: Experience in a Single Tertiary Hospital

OBJECTIVES

To review the cases of atypical squamous cells (ASC), cannot exclude squamous intraepithelial lesion (ASC-H) diagnosed at a single institution and to discuss the interpretation challenges and clinical management of these cases.

STUDY DESIGN

The ASC-H cases diagnosed at our institution from 2006 to 2015 were studied retrospectively; of 159,000 Pap smears, there were 959 cases of ASC of undetermined significance (ASC-US) and 148 cases of ASC-H. We have reviewed the clinical records of the ASC-H cases, and data have been analyzed using SPSS 20.0.

RESULTS

Median age was 43.1 years; 49.6% of the patients had previous cervical cytologies, and 55.9% of them were negative. Following ASC-H diagnosis, another smear was obtained in 97.1% of the cases and in 67.6% a biopsy was performed. Biopsy revealed low-grade dysplasia in 18.8% of the cases, high-grade dysplasia in 27.8%, and infiltrating carcinoma in 2.3%. Patients with significant lesions in histology were younger than patients with negative results (p = 0.08). A diagnosis of ASC-H/squamous intraepithelial lesion in the repeated cytology had a sensitivity of 74.2%, specificity of 39.6%, positive predictive value of 44.8%, and negative predictive value of 70% for the diagnosis of dysplasia.

CONCLUSIONS

ASC-H diagnosis is associated with a high incidence of histological high-grade lesions. A repeat cytology can aid in the selection of high-risk patients, but there may be false-negative results.

Performance of the Cellslide® automated liquid-based cytology system amongst HIV-positive women

Background

Many women undergoing cervical screening as part of a national South African screening programme may be positive for HIV. The performance of liquid-based cytology (LBC) on samples from HIV-positive women needs to be determined.

Objectives

The performance of the Cellslide^® automated LBC system was evaluated as a possible alternative to conventional cytology in a national cervical cancer screening programme.

Methods

Split samples from 348 HIV-positive women attending an HIV treatment clinic in Johannesburg, South Africa were examined by conventional cytology and monolayer LBC methods. All samples were stained, examined and reported in the same manner. Cytotechnologists were blinded to the conventional smear diagnosis if the LBC smear was screened and vice versa.

Results

The same percentage of inadequate smears (1.4%) was obtained by conventional cytology and LBC. Atypical squamous cells of undetermined significance were observed in 5.2% of conventional smears and 4.0% of LBC smears. Low-grade squamous intraepithelial lesions were found in 35.6% of conventional smears and 32.7% of LBC smears. Only one conventional smear was categorised as atypical squamous cells – cannot exclude a high-grade lesion, whereas five such cases were identified on LBC. High-grade squamous intraepithelial lesions were seen in 21.6% of conventional smears and 23.3% LBC smears. No invasive carcinoma was identified.

Conclusion

The performance of the Cellslide^® LBC system was similar to that of conventional cytology in this population of high-risk HIV-positive women, indicating that it may be introduced successfully as part of a cervical cancer screening programme.

Follow-up of women with atypical squamous cells cannot exclude high-grade squamous intraepithelial lesions (ASC-H)

CONTEXT AND OBJECTIVE

The concept that the presence of atypical squamous cells cannot exclude high-grade squamous intraepithelial lesions (ASC-H) was introduced in the 2001 Bethesda System of cervical cytology classification. This nomenclature defines cervical cancer precursor lesions. The objective of this study was to investigate the colpocytological-histological results from a three-year follow-up conducted on a cohort of women with reports of ASC-H who were attended during 2005-2006 at clinics of the Southern Metropolitan Healthcare Service of Santiago, Chile.

DESIGN AND SETTING

Prospective cohort study at primary healthcare clinics in Santiago, Chile.

METHODS

Colpocytological-histological follow-up was conducted over a three-year period on 92 women with cytological reports of ASC-H who were attended at primary healthcare clinics during 2005-2006.

RESULTS

At the end of the follow-up period, high-grade lesions were evaluated and the following outcomes were observed: seven women presented invasive cancer (7.6%), 49 presented high-grade lesions (53.3%), 26 presented low-grade lesions (28.2%) and 10 presented normal results (10.9%). The "Conditional Probabilities Tree Diagram" was used to show the results from tests and the times of lesion detection. It demonstrated that, after a first report of ASC-H, clinical management needed to be interventionist.

CONCLUSION

The follow-up on our cohort of women showed that the majority of uncertain ASC-H diagnoses (82.6%) had abnormal colposcopic results and that during the follow-up using ASC-H smears, two out of every three women developed high-grade lesions.

Abnormal cytology in 2012: management of atypical squamous cells, low-grade intraepithelial neoplasia, and high-grade intraepithelial neoplasia

Cervical cancer and human papillomavirus-related diseases continue to cause significant morbidity and mortality in the United States and worldwide. As we begin to understand the natural course of human papillomavirus infection, and the consequences of both its detection and treatment, changes have been made to our clinical approaches. The purpose of this review is to outline the management guidelines for the management of abnormal cytology. Successful triage of abnormal cytology in 2012 will allow for continued detection of precancerous lesions reducing the incidence of cervical cancer and increasing the detection of early stage disease.

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 (ASC-H) in HIV-positive women

Objective:

South Africa has very high rates of both HIV infection and cervical pathology. The management of ASC-H is colposcopy and directed biopsy, but with so many women diagnosed with HSIL and a dearth of colposcopy centres in South Africa, women with cytologic diagnosis of ASC-H may not be prioritized for colposcopy. The aim of this study was to determine if HIV-positive women with a cytologic diagnosis of ASC-H should undergo immediate colposcopy or whether colposcopy can be delayed, within the context of an underfunded health care setting with so many competing health needs.

Materials and Methods:

A computer database search was performed from the archives of an NGO-administered clinic that offers comprehensive HIV care. All women with a cytologic diagnosis of ASC-H on cervical smears from September 2005 until August 2009 were identified. Histologic follow up was sought in all patients.

Results:

A total of 2111 cervical smears were performed and 41 diagnosed as ASC-H (1.94%). No histologic follow up data was available in 15 cases. Follow up histologic results were as follows: three negative (11.5%), five koilocytosis and/ or CIN1 (19.2%), ten CIN2 (38.5%) and eight CIN3 (30.8%). There were no cases of invasive carcinoma on follow up.

Conclusion:

The current appropriate management of HIV-positive women in low-resource settings with a diagnosis of ASC-H on cervical smear is colposcopy, despite the costs involved. In the future and if cost-effective in developing nations, use of novel markers may help select which HIV-positive women can be managed conservatively and which ones referred for more active treatment. More research in this regard is warranted.

High-grade histologic lesions in women with low-grade squamous intraepithelial lesion cytology from a region of Thailand with a high incidence of cervical cancer

OBJECTIVE

To evaluate the prevalence of and predictors for underlying significant lesions in women with low-grade squamous intraepithelial lesion (LSIL) smears.

METHODS

Records were retrospectively reviewed for 208 women with LSIL who underwent colposcopy and histological evaluation from October 2004 through April 2009.

RESULTS

Mean age of the patients was 38.5 years. Forty-four (21.2%) women were nulliparous; 20 (9.6%) women were postmenopausal; 29 (13.9%) women tested positive for HIV. Thirty-three (15.9%) women were current users of combined oral contraceptive pills. The pathological results of initial colposcopic evaluations were: 63 (30.3%) with cervical intraepithelial neoplasia (CIN) 2-3; 62 (29.8%) with CIN 1; 4 (1.9%) with cervical cancer; and 79 (38.0%) with no epithelial lesion. Current use of combined oral contraceptive pills, a positive HIV test, and multiparity were significant independent predictors for high-grade disease.

CONCLUSION

Approximately one-third of women with LSIL in our population have underlying significant lesions. Current use of combined oral contraceptive pills, a positive HIV test, and multiparity are significant predictors for high-grade lesions.

Living with uncertainty: equivocal Pap test results and the evolution of ASC terminology

Communication of equivocal findings and their significance has been a significant challenge related to Pap testing throughout its history. Terminology to report these findings has changed considerably to accommodate the changes in understanding of cervical neoplasia, and to accommodate new management strategies, tests, and technologies. This article reviews the evolution of terminology for equivocal Pap test findings from the original Papanicolaou classification to the current the Bethesda System 2001 atypical squamous cells terminology, the implication and use of these terms, and the changing landscape of cervical neoplasia screening, which prompted these terminology changes. Emerging issues related to improving risk stratification through the introduction of additional terms and the impact of human papillomavirus testing may alter terminology of equivocal findings in the future.

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.

The role of deeper levels and ancillary studies (p16(Ink4a) and ProExC) in reducing the discordance rate of Papanicolaou findings of high-grade squamous intraepithelial lesion and follow-up cervical biopsies

BACKGROUND

Discordant results of cervical biopsy histology after a cytologic diagnosis of high-grade squamous intraepithelial lesion (HSIL) are often attributed to sampling variation. The purpose of the current study was to determine whether deeper levels and ancillary staining (p16(Ink4a) and ProExC) reduce the discordant rate.

METHODS

A total of 246 cases of HSIL were retrieved from the computerized database from 2005 and 2006. Of these cases, 151 were followed by cervical biopsy. There was cytologic-histologic correlation in 87 cases, as defined by the presence of high-grade (2 or 3) cervical intraepithelial neoplasia (HGCIN). For each discordant biopsy (n = 64), 2 deeper levels for hematoxylin and eosin (H&E) were taken at 30-micro and 90-micro depths, and 4 sections for p16(Ink4a) and ProExC staining were taken at a 60-micro depth. All cytologic and histologic material from these 64 cases was reviewed by 3 cytopathologists. In 2 cases, the original HSIL diagnoses were downgraded and the cases censored from the study.

RESULTS

Fifty-seven of the 62 discordant cases had sufficient tissue for deeper levels and ancillary staining. Two of 57 cases were reclassified to HGCIN. In both of these cases, reclassification was suggested by results of immunostains; however, the H&E sections were necessary for definitive interpretation of the immunostain results.

CONCLUSIONS

In the current study, deeper levels and ancillary staining with p16(Ink4a) and ProExC did not significantly reduce the discordance rate. Although there are many known causes of sampling variation, including factors related to colposcopic technique, regression of infection, and insufficient histologic sectioning, sampling variation remains a valid justification of noncorrelation in women with HSIL followed up by cervical biopsy alone.

Impact of ASC-H terminology on the detection of HSILs in medically underserved California women

In this study we evaluated CDP: EWC, a large public health screening program for low-income women to determine whether the ASC-H term, introduced in the 2001 revision to the Bethesda System, has facilitated the detection of the most serious precancerous cervical lesions such as CIN-II-III/CIS, including accuracy of detection and minimizing diagnostic delays. Pap test and biopsy data from the period 2003-2006 were compared with those from 1995-1999, and included analysis of a subset of rarely and never-screened for each study period. More ASC-H Pap tests were followed by CIN-II+ biopsies (20%) than ASCUS Pap tests (5%). Thirteen percent of ASC-H showed CIN-III/CIS on follow-up biopsy. Following the introduction of ASC-H, negative and LSIL Pap tests followed by CIN-III/CIS biopsies decreased from 5.6% to 0.37% and 9.2% to 4.4%, respectively. Fewer CIN-III/CIS cases were preceded by Pap tests with negative and ASCUS results in 2003-2005 as compared with 1995-1999. The number of days from screening to diagnosis for women aged 25-39 years with ASC-H Pap test results (58 days) was less than for ASCUS results (78 days) for the current study period. In this high-risk multi-ethnic population, ASC-H more effectively communicates equivocal findings likely to represent HSIL leading to more rapid follow-up. The incidence of CIN-II or CIN-III/CIS following ASC-H Pap tests is lower than generally appreciated for this population, including for rarely or never-screened high-risk women. Fewer CIN-III/CIS lesions were detected following negative and ASCUS Pap results. Compliance with follow-up is less than ideal for this population.

Adjunctive human papillomavirus DNA testing is a useful option in some clinical settings for disease risk assessment and triage of females with ASC-H Papanicolaou test results

CONTEXT

Recent guidelines recommend colposcopy for women with atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H). objective: To determine whether adjunctive high-risk human papillomavirus (hrHPV) testing is useful for disease risk assessment in females with ASC-H Papanicolaou (Pap) test results.

DESIGN

High-risk HPV prevalence and histopathologic follow-up data on 1187 females with ASC-H ThinPrep Pap test (TPPT) and hrHPV test results were analyzed.

RESULTS

ASC-H was reported in 1646 (0.59%) [corrected] of 277 400 (270 338 TPPT and 7062 conventional) Pap test results. The difference in ASC-H detection rates between TPPTs and conventional Pap smears was statistically significant (0.60% vs 0.38%; P = .02). High-risk HPV was detected in 589 (49.6%) of 1187 females with ASC-H TPPT and hrHPV testing. The hrHPV DNA-positive rate in females younger than 40 years was 54.7%, significantly higher than the 36.5% in women 40 years and older. Among 505 females with histopathologic follow-up, cervical intraepithelial neoplasia 2/3 was identified in 32.7% of hrHPV-positive females compared with 1.2% in hrHPV-negative females. The sensitivity, specificity, positive predictive value, and negative predictive value of ASC-H cytology in conjunction with hrHPV DNA testing results for detection of cervical intraepithelial neoplasia 2/3 were 96.1% versus 100.0%, 54.0% versus 68.4%, 35.8% versus 20.8%, and 98.1% versus 100.0% in females younger than 40 years and women 40 years and older, respectively.

CONCLUSIONS

Our data suggest that reflex hrHPV testing is a highly useful option for women with ASC-H Pap tests. Females with ASC-H and negative hrHPV testing may be more efficiently managed by follow-up with regular Pap and hrHPV testing rather than universal colposcopy, especially for women 40 years and older.

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.