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

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.

A Comparison of Cytomorphological Features of ASC-H Cells Based on Histopathological Results Obtained from a Colposcopic Target Biopsy Immediately after Pap smear Sampling

Background: To compare the cytomorphological features of atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H) observed in a liquid-based Pap smear with the histopathological features observed in a concurrent colposcopic biopsy specimen obtained immediately after obtaining the Pap smear. Methods: Cytomorphological features such as cytoplasmic differentiation, nuclear/cytoplasm (N/C) ratio, chromatin pattern, thickening of nuclear contour, and the appearance of the nucleolus of 247 ASC-H obtained from 25 liquid-based Pap smear ASC-H cases were compared with those of the cells obtained from biopsied samples. Human papillomavirus (HPV) infection was tested for 39 HPV genotypes using Uniplex E6/E7 polymerase chain reaction method. Results: Of the 25 ASC-H cases, 22 (88%) showed cervical intraepithelial neoplasia grade 1 or greater (CIN1+) and 3 (12%) were benign. HPV infection was detected in 100% CIN1+ cases and 66.7% benign cases. Significant differences such as marked hyperchromasia, thickened nuclear contour, and prominent nucleoli were observed between ASC-H cases with CIN1+ and the benign cases. Conclusion: The presence of small dysplastic cells displaying marked hyperchromasia, thickening of nuclear contour, and prominent nucleoli on Pap smear strongly suggest the presence of CIN in ASC-H cases.

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.

Comparative analysis of cervical cytology screening methods and staining protocols for detection rate and accurate interpretation of ASC-H: Data from a high-volume laboratory in Turkey

BACKGROUND

This study evaluated the effectiveness of the ThinPrep(®) Imaging System (TIS) and ThinPrep(®) Pap Stain (TPPS). A comparative analysis was conducted to determine the detection rates of atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H), the ASC:squamous intraepithelial lesion (SIL) ratio, biopsy follow-up for ASC-H in terms of the screening method used (manual screening [MS] vs. TIS screening [TISS]) and the staining protocol (regular Pap stain [RPS] vs. TPPS).

METHODS

This study was performed over two periods. The RPS period included manually screened slides, whereas the TPPS period included TIS + manually screened slides. All data from the study periods were compared using statistical analysis.

RESULTS

The detection rate of ASC-H was significantly higher during the TPPS period than during the RPS period (0.49% vs. 0.23%); this finding is in contrast to the insignificant difference between the screening method periods. The positive predictive value (PPV) of ASC-H cytodiagnosis for cervical intraepithelial neoplasia of grade 2 or more severe histologies was significantly different between manually screened and TIS slides (22.10% vs. 38.55%), in contrast to an insignificant difference between RPS and TPPS periods (37.14% vs. 29.77%).

CONCLUSION

Implementation of the TIS did not change the ASC-H detection rates appreciably. However, the new technology improved PPV for ASC-H cytodiagnosis and enabled the detection of true disease. Our laboratory statistics indicate that the TPPS is not a superior staining protocol and did not increase our diagnostic accuracy for ASC-H compared with RPS.

HPV testing results and histologic follow-up in women with ASC-H cytology in different age groups

INTRODUCTION

Assessment on human papillomavirus (HPV) testing and disease outcome of atypical squamous cell, cannot exclude high grade squamous intraepithelial lesion (ASC-H) in different age groups is limited in published reports. We reviewed our experience over a 5-year period on ASC-H cytology and correlated age distribution with high-risk HPV (HR-HPV) status and histological follow-up in a large cohort study.

MATERIALS AND METHODS

Women with ASC-H cytology were retrieved from the hospital database. HR-HPV status and histological diagnoses on cervical biopsy or loop electrosurgical excisional procedure specimens were reviewed and correlated to 5 age groups.

RESULTS

Ages of women with ASC-H ranged from 16 to 88 years, with 42% women <30 years and 58% women >30 years. Among 647 cases diagnosed as ASC-H, 96% (618) had HR-HPV testing results, including 68.2% HR-HPV positive and 31.8% HR-HPV negative. HR-HPV positivity of ASC-H gradually decreased from 95.2% in women <20 years to 40.6% in the age group >51 years. Histologic follow-ups were available for review in 80% (517) of the cases. Cervical intraepithelial neoplasia, grade 2 or higher (CIN2+) lesions were found in 40.3% (208) cases, including 92.9% women with HR-HPV-positive/ASC-H and 7.1% of women with HR-HPV-negative/ASC-H. The detection rate of CIN2+ by ASC-H gradually decreased from 51.2% in women <20 years to 18.2% in women >51 years. The majority of postmenopausal women with HR-HPV-negative/ASC-H had atrophy-related change.

CONCLUSIONS

The specificity of ASC-H cytology in detection of cervical CIN2+ lesions is age-dependent: higher in younger women <30 years, but gradually decreased in women >30 years. The vast majority (93%) of CIN2+ lesions were seen women with HR-HPV-positive/ASC-H. HR-HPV testing improves the accuracy and specificity in women with ASC-H in almost all age groups, especially in age groups older than 40 years.

Pap tests and HPV infection

The natural history of human papillomavirus (HPV) is not yet completely understood. But over the past decade, there has been an explosion in knowledge about the virus and its relationship to precancerous and cancerous changes in the genital tract. Recent research in the management of Pap testing, new technologies for Pap screening, and easy access to HPV tests have changed the treatment recommendations in patients with abnormal cytologic results. In this article, Dr Buechler explores these advances and explains how they affect the clinical management of patients with abnormal Pap test results.

Histopathological outcomes of women with abnormal cervical cytology: a review of literature in Thailand

Cervical cytology remains the principal screening method to detect pre-invasive and invasive cervical lesions. Management of abnormal cervical cytology depends on the risk of encountering a significant cervical lesion or high-grade cervical disease. These risks may vary in different areas across the country. Thus, determining the rate of significant cervical lesion associated with each type of abnormal cervical cytology in each area is of critical importance for designing area-specific management approach. This review was conducted to evaluate the rate of high-grade cervical disease among Thai women with abnormal cervical cytology. A relatively high incidence of underlying significant lesions including invasive disease was demonstrated even in those having only minimal smear abnormality. This baseline information is crucial and must be taken into consideration in management of women with abnormal cytological screening to achieve the goals of comprehensive cervical cancer control in Thailand.

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.

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 of atypical squamous cell Pap smears in Iraqi women

OBJECTIVES

To report the prevalence of atypical squamous cells of undetermined significance and atypical squamous cells-cannot exclude high squamous intraepithelial lesion and to determine the possible association of Pap test results with high-risk human papillomavirus and high squamous intraepithelial lesions in women from Duhok, Iraq.

DESIGN

A prospective, observational study was conducted between January 2005 and December 2011. Overall, 596 women with a cervicovaginal Pap test showing atypical squamous cells of undetermined significance and 93 atypical squamous cells-cannot exclude high squamous intraepithelial lesion for whom pathologic follow-up was available were studied. Follow-up consisted of repeat cytology, colposcopy and histology. High risk human papillomavirus DNA testing was performed on exfoliated cervical cells from 106 women, using conventional PCR after at least 36 months from the initial Pap smear.

RESULTS

Significantly high proportions of both atypical squamous cells of undetermined significance (87.9%) and atypical squamous cells-cannot exclude high squamous intraepithelial lesion (62.4%) demonstrated no significant lesion on subsequent follow up. Low squamous intraepithelial lesions were observed in 1.7% of cases of atypical squamous cells of undetermined significance and in 5.4% of atypical squamous cells-cannot exclude high squamous intraepithelial lesion. High squamous intraepithelial lesion was demonstrated in 0.8% and 16.1% respectively. In the latter there was also one case of invasive carcinoma. High-risk HPV DNA was demonstrated in 40% of atypical squamous cells of undetermined significance and 57.1% of atypical squamous cells-cannot exclude high squamous intraepithelial lesions.

CONCLUSIONS

Since both atypical squamous cells of undetermined significance and atypical squamous cells-cannot exclude high squamous intraepithelial lesion identify patients who are at an increased risk for the development of high squamous intraepithelial lesions and a considerable percentage harbor high risk-HPV, both should be retained as diagnostic categories and patients warrant a diligent follow up and testing for high risk-HPV DNA. Colposcopic evaluation and biopsy, when indicated, are a must.

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.

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.

The value of duplicate slides on atypical squamous cells, cannot exclude high-grade intraepithelial lesion

Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H) category was added to the 2001 Bethesda System. ASC-H accounts for a small percentage (0.2-0.6%) of abnormal Pap smears and includes heterogenous group of lesions. There are more high-grade cervical lesions (30-50%) in ASC-H than ASC-US (10-15%). An accurate Pap diagnosis is crucial for appropriate patient follow-up and treatment. A total of 43 consecutive ASC-H cases were collected from October 2007 to March 2008, and all duplicate and the original slides were reviewed blindly at the end of the study. On review of the duplicate Pap slides, 18 cases had diagnostic SIL cells (15 HSIL, 2 LSIL with ASC-H, and 1 LSIL). The duplicate slides could have potentially changed 18 (41.9%) ASC-H diagnoses to a more definitive SIL diagnosis. On review of the original Pap slides, 8 of these 18 cases also had HSIL cells. Twenty-one follow-up cervical biopsies (21/43, 48.8%) showed 12 CIN 2/3, 4 CIN 1, 1 VAIN 1, 2 cervical polyps, 1 negative for dysplasia, and 1 insufficient for diagnosis. The CIN 2/3 rate was 57.1% (12/21) based on the original ASC-H Pap diagnosis. The CIN 2/3 rates were 80% (8/10) with SIL cells on duplicate slides and 36.4% (4/11) without SIL cases on duplicate slides. Our study suggested that duplicate slides were very useful for further classification of ASC-H, but other ancillary tests might be necessary for some cases. We propose a systematic approach using combined duplicate slides and reflex HPV testing to further classify ASC-H.

Cervical cytology of atypical squamous cells, cannot exclude high-grade squamous intra-epithelial lesion: significance of age, human papillomavirus DNA detection and previous abnormal cytology on follow-up outcomes

OBJECTIVE

Despite the usefulness of Pap tests for cancer screening, outcomes can be difficult to predict when atypical squamous cells (ASCs) are identified. According to the 2001 Bethesda system, ASCs can be subdivided into two groups: ASCs of undetermined significance (ASC-US); and ASCs, cannot exclude high-grade squamous intra-epithelial lesion (ASC-H). ASC-H interpretations are uncommon, and studies involving this type of lesion are based on small numbers of cases.

STUDY DESIGN

Cross-sectional, retrospective study of 392 ASC-H cases. The follow-up outcomes of ASC-H cases that were diagnosed during routine primary screening between 2002 and 2008 were investigated, and relationships between clinicopathological parameters were assessed, particularly positive test for high-risk HPV (HPV) DNA, patient age at diagnosis and previous abnormal cytology.

RESULTS

Of the 392 cases, high-grade squamous intra-epithelial lesion (HSIL) was detected in 111 (28.3%) cases, squamous cell carcinoma was detected in 15 (3.8%) cases, low-grade squamous intra-epithelial lesion was detected in 37 (9.4%) cases, reactive change was detected in 178 (45.4%) cases, atrophy was detected in 47 (12.0%) cases, and adenocarcinoma was detected in four (1.0%) cases. The prevalence of HSIL or greater was 27.8% for women aged ≥ 40 years, and 52.3% for women aged <40 years (p<0.001). HPV positivity in ASC-H smears was significantly associated with HSIL or greater, irrespective of age (<40 years, p=0.003; ≥ 40 years, p<0.001). ASC-H with previous abnormal cytology greater than ASC-US showed a significantly higher detection rate for HSIL or greater at follow-up (p<0.001).

CONCLUSIONS

Patient age, positive HPV DNA test and previous abnormal cytology are useful predictors of underlying HSIL or greater in women with ASC-H.

Evaluation of atypical squamous cells on conventional cytology smears: An experience from a screening program practiced in limited resource settings

BACKGROUND

The Bethesda system (TBS) 2001 has subdivided the category of atypical squamous cells (ASC) into: ASC-US (undetermined significance) and ASC-H (cannot exclude high-grade squamous intraepithelial lesion (HSIL)). The present study is an analysis of ASC-US and ASC-H cases diagnosed in a screening program practiced in limited resource settings.

METHODS

During the period January 2005 to December 2008, a total of 9190 smears were received, of which 568 were unsatisfactory. Cases initially diagnosed as ASC-US (n=74) and ASC-H (n=29) on conventional cytology smears were reviewed. Biopsy and human papilloma virus (HPV) results were available in limited cases.

RESULTS

On review, diagnosis of ASC-US was retained in 49 (66.2%) of the 74 initially diagnosed ASC-US cases. Remaining 12 cases were re-labeled as negative for intraepithelial lesion or malignancy (NILM), nine as low-grade squamous intraepithelial lesion (LSIL), three as ASC-H and one case as squamous carcinoma (SCC). Similarly, on review, diagnosis of ASC-H cases was retained in 17 of the 29 initially diagnosed ASC-H cases. Seven cases were re-labeled as NILM, three as HSIL and one case each as ASC-US and SCC. Overall, 8622 cases (96.6%) were diagnosed as NILM, 72 (0.83%) as LSIL, 121 (1.40%) as HSIL, 23 (0.26%) as SCC, 50 (0.57%) as ASC-US cases, 20 (0.23%) as ASC-H, five (0.05%) as atypical glandular cells (AGC) and two cases as adenocarcinomas. Out of 50 ASC-US cases, biopsy in 23 cases showed presence of CIN 1 in 16 cases (69.5%) and CIN 2 in one case (4.34%), while the remaining six cases were negative for CIN/malignancy. The remaining 20 cases with unavailable biopsy results were HPV-positive. Out of 20 ASC-H cases, biopsy in 15 revealed CIN 2 and above in 11 cases (73.3%). Three cases (20%) revealed CIN 1.

CONCLUSIONS

Critical review is helpful in further reducing the number of ASC cases. The percentage of cases with CIN 2 and above is higher with ASC-H cases. The reason for relative increase in HSILs in the present study included referral bias in the screening program.

Comparison of the clinical significance of the Papanicolaou test interpretations LSIL cannot rule out HSIL and ASC-H

Despite the two-tiered classification of dysplasia in The Bethesda System (TBS), rare cases fall into the category squamous intraepithelial lesion (SIL) of indeterminate grade. These Pap tests are often interpreted as "LSIL/ASC-H" or "LSIL" with a comment indicating the presence of cells with features approaching HSIL. Patients with LSIL/ASC-H have a significant risk of CIN 2 or worse (29-61.5%) on follow-up cervical biopsies, similar to the risk of CIN 2 or worse in patients with ASC-H Pap tests (24-68%). The purpose of this study was to compare patients with ASC-H and LSIL/ASC-H Pap tests. Women with LSIL/ASC-H had a slightly lower incidence of CIN 2 or worse (PPV = 35.6%, 95% CI: 29.8-41.4%) on follow-up cervical biopsy than the control ASC-H group (PPV = 40.2%, 95% CI: 31.9-56.3%); this difference was not statistically significant. The difference in the distribution of the biopsy results between the two groups was statistically significant (P < 0.001). The current guidelines for the management of cervical cytologic abnormalities from the American Society for Colposcopy and Cervical Pathology (ASCCP) advocate similar treatment algorithms for both LSIL and ASC-H. The main difference is the option of cytologic follow-up or HPV testing for certain "special populations," as an alternative to colposcopy, for LSIL Pap test results. Based on our results, we recommend (1)LSIL/ASC-H to be added to TBS classification and (2) Pap test cases of LSIL/ASC-H may need to be clinically followed in a manner similar to ASC-H, i.e., colposcopy for all patients.

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.

Prevalence of cervical intraepithelial neoplasia grades II/III and cervical cancer in patients with cytological diagnosis of atypical squamous cells when high-grade intraepithelial lesions (ASC-H) cannot be ruled out

CONTEXT AND OBJECTIVE

The latest update of the Bethesda System divided the category of atypical squamous cells of undetermined significance (ASCUS) into ASC-US (undetermined significance) and ASC-H (high-grade intraepithelial lesion cannot be ruled out). The aims here were to measure the prevalence of pre-invasive lesions (cervical intraepithelial neoplasia, CIN II/III) and cervical cancer among patients referred to Instituto Fernandes Figueira (IFF) with ASC-H cytology, and compare them with ASC-US cases.

DESIGN AND SETTING

Cross-sectional study with retrospective data collection, at the IFF Cervical Pathology outpatient clinic.

METHODS

ASCUS cases referred to IFF from November 1997 to September 2007 were reviewed according to the 2001 Bethesda System to reach cytological consensus. The resulting ASC-H and ASC-US cases, along with new cases, were analyzed relative to the outcome of interest. The histological diagnosis (or cytocolposcopic follow-up in cases without such diagnosis) was taken as the gold standard.

RESULTS

The prevalence of CIN II/III in cases with ASC-H cytology was 19.29% (95% confidence interval, CI, 9.05-29.55%) and the risk of these lesions was greater among patients with ASC-H than with ASC-US cytology (prevalence ratio, PR, 10.42; 95% CI, 2.39-45.47; P = 0.0000764). Pre-invasive lesions were more frequently found in patients under 50 years of age with ASC-H cytology (PR, 2.67; 95% CI, 0.38-18.83); P = 0.2786998). There were no uterine cervical cancer cases.

CONCLUSION

The prevalence of CIN II/III in patients with ASC-H cytology was significantly higher than with ASC-US, and division into ASC diagnostic subcategories had good capacity for discriminating the presence of pre-invasive lesions.

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.

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.

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.

Outcome of "Atypical squamous cells" in a cervical cytology screening program: implications for follow up in resource limited settings

(1) To study the incidence and outcome of "Atypical squamous cells (ASC)" diagnosis in a hospital based cytology screening programme. (2) To work out a feasible strategy for follow up of Atypical squamous cells-undetermined significance (ASC-US) and Atypical squamous cells-cannot exclude high grade squamous intraepithelial lesion (ASC-H) in resource limited settings. A total of 29,475 women were screened cytologically through Pap tests. The epithelial cell abnormalities (ECA) detected on screening were reviewed by the cytopathologists and classified according to Bethesda 2001 system. The women with ASC-US reports were followed up by two repeat cytology tests at 3 and 6 months of the initial visit. The persistent ASC-US cases or the cases which revealed squamous intraepithelial lesion (SIL) on follow up smears; as well as all ASC-H and above cases were referred for coloposcopic evaluation. ASC diagnosis comprised 3.6% of all reports. These were qualified as ASC-US (3.36%) and ASC-H (0.22%). On follow up, only 7 CIN 2 or worse (3.2%) lesions were detected on 218 biopsies in ASC-US category while in ASC-H qualifier 16 CIN 2 and above lesions (30.8%) were picked up on 52 colposcopic biopsies. The difference between ASC-US and ASC-H categories for a CIN 2 or worse outcome was highly significant (P < 0.001). ASC-H qualifier has a high likelihood for an ominous histological outcome and warrants an immediate colposcopic evaluation. On the other hand, ASC-US cases can be managed conservatively by repeat cytology tests at regular intervals without a significant risk of missing a high grade lesion. Diligent screening of cervical smears can judiciously downgrade some cases overcalled as ASC because of inflammatory atypia and thereby reduce referrals in geographic settings with high prevalence of reproductive tract infections. High risk HPV (HR HPV) testing may be a useful adjunct to further reduce referrals by selecting the women who require colposcopic evaluation.

Atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion (ASC-H): a result not to be ignored

OBJECTIVE

The objective of this study was to determine the risk of a clinically significant lesion associated with the diagnosis of atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion (ASC-H) on cervical cytology (Pap smear).

METHODS

This was a retrospective, observational, descriptive study. A computerized database containing cytologic and histologic information for the health region was used to identify women with a diagnosis of ASC-H on a Pap smear performed between January 1 and December 31, 2002. All pertinent pathology data (cytopathology, histopathology, and surgical specimens) were examined. Patients were excluded if they had a diagnosis of cervical cancer, adenocarcinoma in situ (AIS), or high-grade squamous intraepithelial lesion (HSIL) prior to the index Pap smear.

RESULTS

During the study period, 727 of 241 841 Pap smears (0.3%) were reported as ASC-H in 655 patients. Ninety-one patients had a previous diagnosis of cervical cancer, AIS, or HSIL and were excluded from analysis, and 12 patients on review did not have ASC-H. There were no follow-up data for 35 of the remaining 552 patients, leaving 517 patients in the study group. In this group, the rates of histologically proven cervical lesions were 2.9% (15/517) for cervical cancer, 1.7% (9/517) for AIS, and 65.6% (339/517) for HSIL. Women undergoing a procedure that included histological examination were more likely to have a significant lesion discovered.

CONCLUSION

The diagnosis of ASC-H on Pap smear is associated with an appreciable risk of clinically significant disease. Patients with an ASC-H Pap smear result should undergo timely colposcopic and histologic assessment to rule out HSIL, AIS, and cervical cancer.

Is atypical squamous cells that cannot exclude high-grade squamous intraepithelial lesion clinically significant?

OBJECTIVE

To determine the cumulative risk of cervical intraepithelial neoplasia (CIN) 2 or 3 in patients with atypical squamous cells, cannot exclude HSIL (ASC-H).

METHODS

A retrospective analysis was performed to identify patients referred to the dysplasia clinic with ASC-H. Initial evaluation included colposcopy, endocervical curettage, and an ectocervical biopsy, when indicated, in all the patients. A follow-up evaluation was performed at 6 and 12 months. Cumulative histological diagnosis of CIN 2 or 3 at 12 months served as the clinical end point.

RESULTS

Two hundred twenty-nine patients with ASC-H and with a mean age of 32.8 years were evaluated. At the time of initial colposcopy, only 10.0% (23/229; 95% CI = 6.5%-15%) of the patients had histological evidence of CIN 2 or 3. The cumulative risk of CIN 2 or 3 was 12.2% (95% CI = 8%-17%).

CONCLUSIONS

Evaluation of patients with ASC-H with colposcopy does lead to the detection of CIN 2 or 3 but perhaps at a rate lower than previously reported.

Ontario Cervical Cancer Screening Clinical Practice Guidelines

OBJECTIVE

To develop clinical practice guidelines for cervical screening and the primary management of abnormal cytology in Ontario, using an established methodological process.

DATA SOURCES

Primary data sources were relevant articles listed in the Medline (1998 to July 2004), Embase (1998 to July 2004), and Cochrane Library (2004, Issue 2) databases.

STUDY SELECTION

Studies addressing quality or the optimization of cervical screening were considered eligible in the systematic review of the evidence. Specifically, clinical practice guidelines, technology assessments, systematic reviews, and randomized controlled trials were of primary interest. Given the variability of the data, other information sources were considered eligible if there was a demonstrated gap in the published literature.

DATA EXTRACTION

Data were identified and extracted by a methodologist and reviewed by four authors. Results were reviewed and discussed by members of an expert working group consisting of a diverse group of health professionals with expertise in cervical cancer. Data audits were conducted by independent reviewers.

DATA SYNTHESIS

recommendations with evidence ratings were developed through a review of the evidence with expert consensus and were approved by more than 80% of 40 external practitioners who reviewed the document and responded to a standardized survey.

CONCLUSION

The development of comprehensive recommendations on cervical screening in Ontario was feasible using a rigorous methodological process. Recommendations for practice are provided.

Clonality Analysis and Human Papillomavirus Infection in Squamous Metaplasia and Atypical Immature Metaplasia of Uterine Cervix

Atypical immature squamous metaplasia (ISM) of the uterine cervix often has histological features that overlap with the histological characteristics of high-grade cervical intraepithelial neoplasia. To identify the cellular basis and clinical significance of atypical immature metaplasia (AIM), 10 cases of AIM were analyzed for the clonal status, and the presence of human papillomavirus (HPV) infection. The physical status of HPV was also evaluated in HPV type 16 (HPV-16)-positive cases. Squamous metaplasias with no nuclear atypia (29 mature squamous metaplasias [SMs]) and a single case of ISM were analyzed as a control. Nine AIMs, 20 SMs, and a single case of ISM were informative for clonal analysis. Monoclonal composition of the lesion was demonstrated in 8 (89%) of 9 AIMs, but only in 2 (10%) of 21 cases of SM without atypia (AIM vs SM + ISM, 8/9 vs 2/21; P < 0.0001). High-risk HPV was detected in 6 (60%) of 10 AIMs, all were HPV-16, but only in 3 (13%) of 24 SMs with no atypia (2/23 SM and 1/1 ISM). The frequency of high-risk HPV infection was also significant between AIMs and SM with no atypia (6/10 vs 3/24; P < 0.001). Among the cases, which were informative for clonal analysis, all 5 AIMs positive for high-risk HPV were monoclonal in composition. Physical status of HPV was examined in HPV-16-positive cases. Human papillomavirus type 16 was present as a mixture of episomal form and integrated form in 4 of 6 AIMs. These observations imply that unlike SMs with no atypia, which arises as a result of reactive or inflammatory process, lesions with the histological characteristics of AIM may be indeed true precursors of cervical carcinoma.

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.

Human papillomavirus testing in primary cervical screening and abnormal Papanicolaou management

Human papillomavirus (HPV) infection is a necessary cause of cervical cancer; HPV testing capitalizes on this fact to maximize the clinical benefits of cervical screening and abnormal Papanicolaou (Pap) test management. HPV tests in combination with Pap tests are 96% to 100% sensitive for detection of cervical intraepithelial neoplasia (CIN) 2/3 and cancer. However, because HPV infection is common in young women and most commonly transient, HPV testing is not recommended as part of primary cervical screening for women younger than 30 years of age. HPV testing is recommended for women of any age for the clarification of atypical cells of undetermined significance (ASC-US) and as an option for follow-up of women with HPV-positive ASC-US, atypical squamous cells "cannot rule out high-grade," or low-grade squamous intraepithelial lesions not found to have CIN 2/3. HPV testing is also recommended as an alternative to colposcopy and/or cytology for follow-up of treated cases. Proper use of HPV testing improves the management of women with cytologic abnormalities. In addition, a negative HPV test in combination with a normal Pap test result in women age 30 and older allows the safe extension of the interval between cervical screenings. Thus, when used properly, HPV testing may reduce morbidity and mortality and do so in a cost-effective manner.

Clinical implications of the diagnosis “atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion” in pregnant women

BACKGROUND

Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H) has a high predictive value for high-grade intraepithelial lesion (HSIL) in the general population. However, the significance of ASC-H in pregnant women remains to be elucidated. The objective of this study was to investigate the clinical implications and pathologic significance of ASC-H in pregnant women, so that these patients will be managed appropriately.

METHODS

All Papanicolaou tests that were diagnosed as ASC-H in pregnant women over 1.5 years (total, 60 women) were reviewed and correlated with histologic and/or cytologic follow-up. High-risk type of human papillomavirus (HPV) status was also correlated with follow-up findings. The following cytomorphologic parameters were evaluated for each woman and were compared between the squamous intraepithelial lesion (SIL) follow-up group and the benign follow-up group: inflammatory background, the number of atypical cells, cell arrangement pattern, nuclear irregularity/grooves, hyperchromasia, and cell shape.

RESULTS

Among 30 women who had histologic follow-up, 3 women (10%) had HSIL, and 13 women (43%) had low-grade intraepithelial lesion (LSIL). Among 32 women who had cytologic follow-up, 2 women (6%) had HSIL, 3 women (9%) had LSIL, 1 woman (3%) had ASC-H, and 3 women (9%) had atypical squamous cells of undetermined significance (ASCUS). HPV was detected in 24 of 43 women (56%). The cytomorphologic features were similar in the SIL follow-up group and the benign follow-up group. No specific cytomorphologic features that predicted underlying SIL were identified.

CONCLUSIONS

ASC-H in pregnant women had a lower predictive value for an underlying HSIL compared with the general population. A positive HPV test result was not a good indicator for an underlying SIL, but a negative result appeared to be useful for ruling out an underlying HSIL. Because of low positive predictive value for HSIL and the difficult colposcopic examination, a more conservative follow-up may be reasonable for pregnant women who have a diagnosis of ASC-H. HPV testing may be used as an adjunctive test.

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.

Spectrum of epithelial cell abnormalities of uterine cervix in a cervical cancer screening programme: implications for resource limited settings

OBJECTIVE

(1) To compute the frequencies and peak age incidences of epithelial cell abnormalities (ECA) of uterine cervix in a cytology-based screening programme and (2) to analyze the comparative frequencies of squamous intraepithelial lesions (SIL) and malignancies in age groups <40 and > or =40 years, in order to assess the implications for screening protocol in resource limited settings.

STUDY DESIGN

Pap smears form 29,475 women were cytologically screened over a 4-year period as a part of hospital-based screening programme. The frequencies, peak age incidences and mean age of various ECA detected were computed. The data was further stratified in to age groups <40 (Gp 1) and > or =40 (Gp 2) and comparative profile of the lesions was analyzed.

RESULTS

On cytologic screening of the smears 5.6% ECA were detected. Atypical squamous cells-undetermined significance (ASC-US) and low grade SILs (LSIL) were diagnosed more frequently in Gp 1 (p<0.001) while atypical glandular cells (AGC) and malignancies were more significantly more frequent in Gp 2 (p<0.001). The frequency of HSIL was similar in the two groups. The SILs predominated in the fourth decade while the malignant lesions were most frequent in age >50 years. The mean age for LSIL and HSIL was 34.7 and 37.7 years, respectively, while for malignancy it was 51.8 years thus corroborating the hypothesis that a prolonged latent phase exists between the precursor lesions and the onset of invasive cancer.

CONCLUSIONS

Since the goal of any screening programme should be to pick up majority of the precursor lesions and not frank cancers, it is desirable to initiate screening before 40 years of age. The WHO recommendation of once in a life time screening between 35 and 40 years of age seems appropriate for resource limited settings like ours.

ASC-H in Pap test--definitive categorization of cytomorphological spectrum

OBJECTIVE

The American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines for management of ASC-H is colposcopic examination followed by biopsy. HPV testing (HPVT) is recommended after a negative biopsy result. More definitive interpretation of ASC-H could prevent discomfort and minimize the cost. The purpose of this study was to evaluate association of various cytomorphological patterns of ASC-H with various clinical scenarios.

METHODS

We reviewed SurePath (TriPath Imaging, Inc. Burlington, NC, USA) cervical smears interpreted as ASC-H in 161 women (mean age, 37 {15 to 78} years), over 24 months (2002 to 2003). HPVT (Digene, Hybrid Capture II HPV test, Digene Corporation, Gaithersburg, MD, USA) was performed in 20% of cases (33/161) and biopsy results were available in 54 cases (19 with and 35 without HPVT).

RESULTS

HPVT was positive in 64% (21/33) cases, and negative in 36% (12/33) cases. In the follow-up biopsies of 71% (15/21) of cases with positive HPVT, 27% showed HPV changes or CIN1, 27% showed CIN2-3, and 46% were negative for epithelial abnormality. Follow-up biopsies from cases with negative HPVT (33%, 4/12 cases), 8% showed CIN1 and 25% were negative for any epithelial abnormality. Six cytomorphological patterns of ASC-H correlated with different clinical categories in relation to HPVT and biopsy results. 35% (19 out of 54 ASC-H cases in which biopsy results were available) could be interpreted definitively as HSIL by cytopathology, 11% (6/54) cases as LSIL with cyanophilic atypical parakeratotic pattern, and 31% (17/54) cases as reactive, with HPV status. The interpretation had to be continued as ASC-H in 22% (12/54) cases.

CONCLUSION

ASC-H demonstrated a spectrum of cytomorphological patterns. Some of these patterns in liquid-based cervical smears may be more specifically interpreted as LSIL, HSIL, or benign if HPV status is known.

Atypical squamous cells, cannot exclude high grade intraepithelial lesion (ASC-H): Does HPV matter?

The role of human papillomavirus (HPV) in cases diagnosed as atypical squamous cells, cannot exclude high squamous grade intraepithelial lesion (ASC-H) in cervical specimens is not well established. The objective of this study is to evaluate the role of HPV status in cases of ASC-H in a major cancer center. One hundred thirty-two patients with a diagnosis of ASC-H were identified over a 4-yr period in our institution. Forty-four of 132 cases were evaluated for high-risk HPV and had biopsy follow-up. The positive predictive value (PPV) of ASC-H for high-grade squamous intraepithelial lesions overall was 32% while PPV of ASC-H with associated HR HPV was 42%. This increase was statistically significant with P = 0.003 and suggest that HPV testing might be useful to increase the PPV of ASC-H.

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.

Should women with atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion, receive reflex human papillomavirus-DNA testing?

BACKGROUND

The 2001 American Society for Colposcopy and Cervical Pathology Consensus Guidelines recommend that women who have Papanicolaou (Pap) smears diagnosed as atypical squamous cells (ASC), cannot exclude high-grade squamous intraepithelial lesion (HSIL) (ASC-H) should be referred for immediate colposcopic examination. The objective of this pilot study was to evaluate whether reflex human papillomavirus (HPV)-DNA testing performed on smears diagnosed as ASC-H may obviate the need for immediate colposcopic examination.

METHODS

All ThinPrep Pap smears that were diagnosed as ASC-H or atypical squamous metaplastic cells (ASMT) between 2001-2003 and that had HPV-DNA testing and subsequent histologic and/or cytologic follow-up were evaluated. Those smears that were diagnosed as ASMT were reviewed and reclassified under the 2001 Bethesda System as either ASC of undetermined significance (ASCUS) or ASC-H. Smears that were diagnosed as ASCUS were excluded from the study.

RESULTS

The study included of 48 smears that were diagnosed as ASC-H. All patients with biopsy-proven HSIL had positive high-risk (HR)-HPV results (100% negative predictive value). Approximately 80% of patients with ASC-H who had biopsy-proven, low-grade intraepithelial lesion on follow-up had positive HR-HPV results. Among the patients who had ASC-H with negative follow-up, 50% had positive HR-HPV results, and 50% had negative HR-HPV results.

CONCLUSIONS

Among patients with ASC-H, a negative HR-HPV result was found to be an excellent predictor of the absence of HSIL. The results of this pilot study suggested that HPV-DNA testing may serve as a means to better select which patients with ASC-H on Pap smear should undergo colposcopic examination. This approach potentially may reduce medical costs and eliminate the need for routine colposcopic examination among patients with ASC-H Pap smears.

Significance of atypia in conventional Papanicolaou smears and liquid-based cytology: a follow-up study

The diagnosis of atypical squamous epithelial cells, borderline nuclear changes, is associated with some controversy, as it encompasses benign, reactive, as well as possible neoplastic conditions. The aim of this study was to evaluate the follow-up diagnoses of cytological atypia in conventional Papanicolaou smears (CP) and liquid-based samples by the ThinPrep Pap Test (TP). A total of 1607 CP smears from 1 January 2000 to 31 December 2000 and 798 TP samples from 1 January 2002 to 31 December 2002 diagnosed as atypia were included. The results show that the detection rate of atypia in cervical cytological samples was reduced by 41.3% (P < 0.001) in TP compared with CP. Cytological and histological follow-up data showed the presence of neoplastic lesions in 34.7% of patients screened by TP versus 22.3% of patients screened by CP, corresponding to a 55.6% increase in TP (P < 0.001). Follow-up diagnosis of mild dysplasia was seen more than twice as often in TP than in CP (12.8% versus 5.0%, P < 0.001). The prevalence of moderate and severe dysplasia was significantly increased with 26.7% in TP compared with CP (21.9% versus 17.2%, P < 0.01). In conclusion, the ThinPrep Pap Test yielded a significant decrease in atypia rates compared with the conventional Papanicolaou test. In subsequent follow-up the percentage of neoplastic lesions was significantly increased in the ThinPrep Pap Test samples.

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.