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Vrdoljak-Mozetič D, Štemberger-Papić S, Verša Ostojić D, Rubeša R, Klarić M, Eminović S. Pitfalls in Gynecological Cytology: Review of the Common and Less Frequent Entities in Pap Test. Acta Cytol 2024; 68:281-298. [PMID: 38834045 DOI: 10.1159/000539637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 05/31/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Pitfalls in Pap test could be defined as false positive, false negative, or underdiagnosed results which can lead to unnecessary diagnostic procedures or delayed and inadequate treatment. It can be a consequence of misinterpretation of certain morphological entities which are described in this paper. SUMMARY The paper presents an overview of the morphological features and look-alikes of the common sources of pitfalls such as atrophy, repair, intrauterine device change, tubal metaplasia, hyperchromatic crowded groups, and radiation changes. Rare causes of pitfalls such as Arias-Stella changes, pemphigus, tumor diathesis per se, rare types of cervical cancer, including verrucous and papillary squamous cell cancer, gastric type, and endometrioid adenocarcinoma are also described. KEY MESSAGES The awareness of pitfalls in cervical cytology is important for cytopathologists and clinicians to avoid future errors. Review of Pap tests with erroneous diagnosis is important for quality control in cytology laboratory, and it must be considered an educational- and experience-building procedure. Cytopathologist should not pull back in significant diagnoses, especially in human papillomavirus-negative cases.
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Affiliation(s)
- Danijela Vrdoljak-Mozetič
- Clinical Department of Pathology and Cytology, Clinical Hospital Center Rijeka, Rijeka, Croatia
- Department of General Pathology and Pathological Anatomy, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Snježana Štemberger-Papić
- Clinical Department of Pathology and Cytology, Clinical Hospital Center Rijeka, Rijeka, Croatia
- Department of General Pathology and Pathological Anatomy, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Damjana Verša Ostojić
- Clinical Department of Pathology and Cytology, Clinical Hospital Center Rijeka, Rijeka, Croatia
| | - Roberta Rubeša
- Clinical Department of Pathology and Cytology, Clinical Hospital Center Rijeka, Rijeka, Croatia
- Department of General Pathology and Pathological Anatomy, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Marko Klarić
- Clinic of Gynecology and Obstetrics, Clinical Hospital Center Rijeka, Rijeka, Croatia
- Department of Gynecology and Obstetrics, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Senija Eminović
- Clinical Department of Pathology and Cytology, Clinical Hospital Center Rijeka, Rijeka, Croatia
- Department of General Pathology and Pathological Anatomy, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
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Torous VF. Challenging lesions in cervical cytology: The elusive HSIL. Cytopathology 2024; 35:48-59. [PMID: 37706620 DOI: 10.1111/cyt.13303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/08/2023] [Accepted: 08/15/2023] [Indexed: 09/15/2023]
Abstract
Cervical cytology has been an integral part of cervical cancer screening since the mid-20th century with the implementation of screening protocols utilising Pap testing. During that time, cervical cancer has gone from the leading cause of cancer deaths in women to not even appearing in the top 10 causes of US cancer deaths. However, despite its long and widespread use, cervical cytology remains a diagnostically challenging area in the practice of cytopathology. Of particular importance for diagnosticians is the accurate diagnosis of high-grade squamous intraepithelial lesions (HSILs), given the significant risk of progression to invasive cervical cancer and the importance to patient management. Therefore, this review is presented in order to highlight the diagnostic features of HSIL, its various appearances, and important benign and neoplastic differential considerations with an emphasis on morphological clues that can aid in distinguishing between these different processes.
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Affiliation(s)
- Vanda F Torous
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Torous VF. Cervicovaginal Papanicolaou tests in transgender men: Cytomorphologic alterations, interpretation considerations, and clinical implications. Cancer Cytopathol 2023; 131:626-636. [PMID: 37358041 DOI: 10.1002/cncy.22731] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/21/2023] [Accepted: 05/10/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND The transgender population faces unique psychosocial and physical obstacles to cervical cancer screening. Additionally, most individuals undergo masculinizing testosterone hormone therapy, and the physiologic changes can cause cytomorphologic alterations that may mimic lesions. Although the literature on cervicovaginal cytology is growing in this patient population, it is still limited. METHODS The pathology information system was queried for all Papanicolaou (Pap) tests from transgender men from January 2013 to February 2023. The original diagnostic categories were catalogued. Cases were reviewed to evaluate the cytomorphologic alterations. Clinical data were also sought, including whether the sample was self-collected. Two comparison groups were established: one was a postpartum atrophic group and the other was an all-comer group. RESULTS A total of 51 cases from 43 individuals were identified, with a mean age of 31 years. Approximately a third of cases (18 of 51; 35%) were self-collected. The abnormal rate was low, with 5.9% of cases rendered atypical squamous cells of undetermined significance on original review and no lesions identified. The Pap unsatisfactory rate according to original reports was 3.9%. This increased to 13.7% when the cases were rereviewed, which was significantly higher than the all-comer comparison group. The unsatisfactory rate did not correlate with self-collection. Atrophy was a prevalent cytomorphologic alteration, with the vast majority of cases (92%) showing at least mild atrophy. Small blue cells and transitional cell metaplasia were seen in many cases (53% and 43%, respectively). CONCLUSIONS There are clinical and morphologic considerations that are distinct to the transgender patient population. Laboratory personnel and diagnosticians need to be aware of these in order to optimize patient care.
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Affiliation(s)
- Vanda F Torous
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Sugisawa A, Toyoda Z, Tanabe Y, Uehara K, Oshiro A, Yamazato R, Sakamoto C, Yogi S, Kurima K, Kina S, Sakiyama M, Kinjo T. Cytological characteristics of premalignant cervical epithelial lesions in postmenopausal women based on endocrine indices and parakeratosis. Menopause 2023; 30:193-200. [PMID: 36696644 DOI: 10.1097/gme.0000000000002125] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To identify useful cytological findings for detecting premalignant lesions in postmenopausal women, cervicovaginal smear samples were analyzed and compared between women with or without premalignant lesions based on endocrine indices and presence of parakeratosis (PK). METHODS The cervicovaginal smear samples of postmenopausal women with premalignant lesions (n = 94) and those who were without (n = 344), who were diagnosed between 2012 and 2014 were retrieved and analyzed. Women cytologically diagnosed with malignancy or those with suspicion of malignancy were excluded from this study. Cytological endocrine indices, such as the maturation index (MI) and eosinophilic index (EI) and the prevalence of PK were compared between the groups and analyzed using the 2 × 2 χ2 test. The association of endocrine indices combined with the presence of PK and histological findings was also evaluated. RESULTS Postmenopausal women with premalignant lesions had higher endocrine indices (EI of ≥11%; 65% vs. 43%, P < 0.01, f = 0.18) and a higher prevalence of PK positivity (PK ≥ 1; 46% vs. 7%, P < 0.01, f = 0.44) than those without lesions. Further analysis indicated that the combination of high EI and the presence of PK in postmenopausal women with cytological premalignant cases was highly associated with histological squamous intraepithelial lesions (SIL) (86% in women with premalignant lesions vs. 53% in those without; P = 0.01, f = 0.34). CONCLUSION Our research demonstrated that high EI and PK positivity were correlated with SIL in postmenopausal women. These cytological findings could provide potential diagnostic clues for detecting dysplasia.
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Affiliation(s)
| | | | - Yasuka Tanabe
- From the Division of Morphological Pathology, Department of Basic Laboratory Sciences, School of Health Sciences, University of the Ryukyus, Okinawa, Japan
| | - Karina Uehara
- From the Division of Morphological Pathology, Department of Basic Laboratory Sciences, School of Health Sciences, University of the Ryukyus, Okinawa, Japan
| | - Aya Oshiro
- From the Division of Morphological Pathology, Department of Basic Laboratory Sciences, School of Health Sciences, University of the Ryukyus, Okinawa, Japan
| | - Reo Yamazato
- From the Division of Morphological Pathology, Department of Basic Laboratory Sciences, School of Health Sciences, University of the Ryukyus, Okinawa, Japan
| | - Chiharu Sakamoto
- From the Division of Morphological Pathology, Department of Basic Laboratory Sciences, School of Health Sciences, University of the Ryukyus, Okinawa, Japan
| | | | - Kiyoto Kurima
- From the Division of Morphological Pathology, Department of Basic Laboratory Sciences, School of Health Sciences, University of the Ryukyus, Okinawa, Japan
| | - Shinichiro Kina
- Department of Molecular Pharmacology and Oncology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Michiyo Sakiyama
- the Lifestyle Related Disease Medical Center, Naha Medical Association, Okinawa, Japan
| | - Takao Kinjo
- From the Division of Morphological Pathology, Department of Basic Laboratory Sciences, School of Health Sciences, University of the Ryukyus, Okinawa, Japan
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Torous VF, Pitman MB. Interpretation pitfalls and malignant mimics in cervical cytology. J Am Soc Cytopathol 2020; 10:115-127. [PMID: 32732114 DOI: 10.1016/j.jasc.2020.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/06/2020] [Accepted: 06/11/2020] [Indexed: 10/24/2022]
Abstract
Cervical cytology has remained a diagnostically challenging area despite its long and widespread use. At least part of this challenge has stemmed from the cytomorphologic overlap between benign and neoplastic processes. The present review has highlighted select benign processes that present diagnostic pitfalls. For each of these, we have discussed the pertinent cytologic features and emphasized the morphologic clues that will aid in distinguishing the benign entities from the neoplastic processes they mimic.
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Affiliation(s)
- Vanda F Torous
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Martha B Pitman
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Relationship Between Pelvic Organ Prolapse and Non-Human Papillomavirus Pap Smear Abnormalities. Female Pelvic Med Reconstr Surg 2017; 24:315-318. [PMID: 28708758 DOI: 10.1097/spv.0000000000000448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine the association between pelvic organ prolapse (POP) and non-human papillomavirus (HPV) Papanicolaou (Pap) smear abnormalities. METHODS This was a retrospective cohort study of women aged 40 to 70 years who presented for consultation at our institution between 2010 and 2015 and had results of a Pap smear and HPV test available within 5 years of their visit. We extracted demographic information, medical and social history, Pap smear, and HPV results from the electronic medical record. Associations between the presence of POP and non-HPV Pap smear abnormalities were estimated using univariable and multivariable analyses. RESULTS We reviewed 1590 charts and excluded 980 women, leaving 610 women in the study: 183 with POP and 427 without POP. Women with POP were significantly older (58.2 ± 7.2 vs 55.6 ± 6.6, P < 0.01) and more likely to have a remote (>10 year) history of abnormal Pap smear (24.0% vs 14.8%, P < 0.01). The rate of non-HPV-associated abnormal Pap smears was higher in the POP group than in the non-POP group (12/183 [6.6%] vs 12/427 [2.8%], P = 0.029). In the POP group, the rate of non-HPV Pap smear abnormality was significantly associated with increasing prolapse stage (stage 1: 0/16 [0%], stage 2: 5/77 [6.5%], stage 3: 3/73 [4.1%], stage 4: 4/17 [23.5%]; P = 0.02). After controlling for age and remote history of abnormal Pap smear, the odds ratio for non-HPV Pap smear abnormalities in the POP group remained significant (2.49; 95% confidence interval, 1.08-5.79). CONCLUSIONS Human papillomavirus-negative Pap smear abnormalities may be related to POP. Our findings have important implications for surgeons seeking to leave the cervix in situ in women with POP.
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Sun L, Wang PH, Lee CH, Fu TF, Chou MM, Hwang SF, Ke YM, Hsu ST, Lu CH. Clinical parameters associated with absence of endocervical/transformation zone component in conventional cervical Papanicolaou smears. Taiwan J Obstet Gynecol 2016; 55:81-4. [PMID: 26927255 DOI: 10.1016/j.tjog.2014.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2014] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To study clinical factors predicting the absence of endocervical/transformation zone (EC/TZ) components of conventional cervical Papanicolaou (Pap) smears. MATERIALS AND METHODS The medical charts of patients who received Pap smears between March 2006 and August 2006 in the hospital were reviewed. The results of their Pap smears were retrieved while their demographic and clinical information were obtained from the medical charts. After excluding 378 cases with incomplete demographic data and 1397 cases with a history of pelvic irradiation, pelvic malignancy, and hysterectomy, 5662 cases were enrolled for data analysis. The relationship between clinical parameters and the absence of EC/TZ component was analyzed by Pearson Chi-square tests with Yates continuity correction and binary logistic regression tests. RESULTS The incidence of satisfactory but absence of EC/TZ component was 8.7% (491/5662). Pregnancy increased the absence of EC/TZ component [odds ratio (OR}: 2.84, 95% confidence interval (CI): 2.14-3.77, p<0.0001]. Postpartum status and endocervical polyps decreased incidence (OR: 0.61, 95% CI: 0.38-0.98, p = 0.043 and OR: 0.33, 95% CI: 0.25-0.44, p<0.0001, respectively). CONCLUSIONS Pregnancy is the only clinical factor associated with increased incidence of absence of EC/TZ cells. For these pregnant women undergoing a Pap smear, a more effective strategy may be needed to get a satisfactory smear with adequate EC/TZ components.
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Affiliation(s)
- Lou Sun
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Chen-Hui Lee
- Department of Pathology and Laboratory Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tsai-Feng Fu
- Graduate Institute of Biomedicine and Biomedical Technology, National Chi Nan University, Nantou County, Taiwan
| | - Min-Min Chou
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Sheau-Feng Hwang
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yu-Min Ke
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-Tien Hsu
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan
| | - Chien-Hsing Lu
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Pathology and Laboratory Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Institute of Biomedical Sciences, National Chung-Hsing University, Taichung, Taiwan; Rong-Hsing Research Center for Translational Medicine, National Chung-Hsing University, Taichung, Taiwan.
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Histologic and Cytologic Effects of Vaginal Estrogen in Women With Pelvic Organ Prolapse. Female Pelvic Med Reconstr Surg 2013; 19:34-9. [DOI: 10.1097/spv.0b013e318278cc40] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lu CH, Chang CC, Chang MC, Chen SJ, Jan YJ, Fu TF, Ho ESC. Clinical parameters associated with unsatisfactory specimens of conventional cervical smears. Diagn Cytopathol 2011; 39:87-91. [PMID: 20091895 DOI: 10.1002/dc.21329] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Although The Bethesda System 2001 attempted to standardize the criteria for specimen adequacy, much confusion still exists, which includes the significance of unsatisfactory smears, the causes and clinical conditions related to unsatisfactory smears, and the appropriate management of unsatisfactory smears. The aim of this study is to find out the clinical factors associated with unsatisfactory cervical smears. We reviewed the medical charts of patients who received conventional Pap smears between March 2006 and August 2006 in a tertiary care center. After excluding 378 cases with incomplete demographic data, the clinical data of 7,059 cases were processed for analysis. Clinical parameters retrieved included: history of pelvic malignancy, pelvic irradiation, conization, hysterectomy, pregnancy status, within 3-months postpartum. Vaginal bleeding, abnormal vaginal discharge, intrauterine device, and cervical polyps found during pelvic examinations were also documented. The 1,397 cases with history of pelvic irradiation, pelvic malignancy, and hysterectomy were excluded. Finally, 5,662 cases were enrolled for data analysis. The relationship between clinical parameters and unsatisfactory smears were analyzed by Pearson's chi-square test with Yates' continuity correction and multivariate binary logistic regression test. The incidence of unsatisfactory smears was 4.5% (252/5,662). Clinical parameters correlated with unsatisfactory smears were postpartum status (OR = 1.92, 95% CI = 1.23-3.01, P = 0.004), vaginal bleeding (OR = 2.02, 95% CI = 1.30-3.16, P = 0.002), and endocervical polyps (OR = 2.62, 95% CI = 1.39-4.947, P = 0.003). In conclusion, if any of these parameters are noted prior to obtaining a Pap smear, optimal collecting devices, better sampling techniques, and liquid-based cytology should be considered to decrease the incidence of unsatisfactory smears.
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Affiliation(s)
- Chien-Hsing Lu
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, 160 Chung-Kang Road Sec. 3, Taichung City, Taiwan.
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Halford J, Walker KA, Duhig J. 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. Pathology 2010; 42:23-7. [PMID: 20025476 DOI: 10.3109/00313020903434363] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Jennifer Halford
- Cytology Department, QML Pathology, Brisbane, Queensland, Australia.
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