Clinical significance of atypical glandular cells on cervical cytology

Correlation of immediate prevalence of cervical precancers and cancers with HPV genotype and age in women with atypical glandular cells cytology: A retrospective analysis of 369 cases

BACKGROUND

This study aims to assess the immediate risk of cervical precancers and cancers in women with atypical glandular cells (AGC) cytology, based on high-risk human papillomavirus (hrHPV) genotypes and age.

METHODS

A retrospective analysis was conducted on 369 cases of AGC with immediate follow-up biopsy results, including 299 AGC-not otherwise specified (NOS) and 70 AGC-favor neoplastic (FN).

RESULTS

Among the 369 AGC cases, 127 tested positive for hrHPV (34.4%). The predominant high-risk type was other 11 genotypes (44.1%), followed by 16+ (29.1%), 18/45+ (26.0%), and 16 and 18/45 double-positive (0.79%). Precancers and cancers were detected in 30.4% (112 of 369) and 9.8% (36 of 369) of cases, respectively. The HPV-18/45+ group had notably higher adenocarcinoma in situ and adenocarcinoma (AIS+) prevalence compared to other 11 genotype groups (p < .0001 and p = .001, respectively). The HPV-16+ group showed significantly higher high-grade cervical squamous epithelial lesion and squamous cell carcinoma prevalence than other 11 genotype groups (p < .0001 and p = .017, respectively). Using 40-year cutoff, older women had significantly higher prevalence of abnormal glandular lesion+ lesions (17.6% vs. 7.6%, p = .005) and adenocarcinoma (AC) (12.4% vs. 2.5%, p = .001). Using 50-year cutoff, older women had higher prevalence of squamous cell carcinoma (SCC) (3.3% vs. 0.4%, p = .042) and AC (15.2% vs. 5.8%, p = .005). Subgroup analysis revealed that AGC-FN women showed more severe cervical pathology than AGC-NOS women (p < .001).

CONCLUSIONS

AGC women have a significantly increased risk of cervical precancerous lesions and cancer. HPV genotyping and patient age factors need to be taken into consideration in the clinical management process of AGC patients.

Assessment of Human Papillomavirus Non-16/18, Type-Specific Risk for Cervical Intraepithelial Neoplasia Grade 3 or Worse Among Women With Cervical Atypical Glandular Cells

OBJECTIVE

To evaluate the risk for cervical intraepithelial neoplasia grade 3 (CIN 3) or worse (including adenocarcinoma in situ [AIS] and invasive cervical cancer) associated with non-16/18 human papillomavirus (HPV) types (other HPV) among women with atypical glandular cells (AGC) in cervical cytology.

METHODS

This population-based cohort study evaluates the risk of CIN 3 or worse associated with other HPV types. Human papillomavirus genotyping was performed on Pap tests collected in Sweden from 341 women with AGC that were positive for other HPV types from February 17, 2014, to December 31, 2018. The women were followed for histopathologic outcomes using comprehensive registry linkages until December 31, 2019. Cumulative incidence proportions of CIN 3 or worse by specific HPV type were calculated using 1-minus Kaplan-Meier function. Hazard ratios (HRs) for CIN 3 or worse were generated using multivariate Cox regression.

RESULTS

Of 341 women, 134 (39.3%) had CIN 3-AIS, but there were only five (1.5%) women in the cohort with invasive cervical cancer. Human papillomavirus 45 preceded 80.0% of invasive cervical cancer cases. Among women positive for HPV33, 82.9% (95% CI 58.0-97.3%) had CIN 3 or worse during follow-up. Positivity for HPV31 conferred the highest HR for CIN 3 or worse relative to other types, both in primary cytology and primary HPV screening (HR 2.71, 95% CI 1.47-5.00 and HR 3.41, 95% CI 1.95-5.96, respectively).

CONCLUSION

Among non-16/18 HPV types in AGC, HPV31 and 33 had the highest risk for CIN 3 or worse, whereas most of the women with invasive cancer were positive for HPV45. Extended HPV genotyping may be helpful for the management of AGC.

Clinical Diagnostic Value of Atypical Glandular Cells in Cervical Cytology: A Single Center Experience From China

OBJECTIVE

This study aimed to investigate the diagnostic value of atypical glandular cells (AGCs) by analyzing the prevalence and histopathology of AGCs according to cervical cytology.

METHODS

The authors retrospectively reviewed and analyzed the demographic characteristics and histopathological outcomes including pathological diagnosis, pathological site, and epithelial distribution of the AGC cases that were diagnosed by cervical cytology.

RESULTS

A total of 387 AGC patients with follow-up records were included. Among them, the prevalence of AGC-not otherwise specified (NOS) and AGC-favor neoplastic (FN) was 73.39% (284/387) and 26.62% (103/387), respectively. The high-risk human papillomavirus (hr-HPV)-positive rate was higher in AGC-FN than in AGC-NOS ( p = .002). The difference in pathological severity was statistically significant between hr-HPV-positive and negative AGC patients ( p = .010). Hr-HPV-positive AGC mainly occurs in cervical diseases, whereas hr-HPV-negative AGC is mainly related to endometrial lesions. Precancerous or malignant lesions were found in 36.43% (141/387) of AGC cases and were more commonly seen in AGC-FN than AGC-NOS ( p < .001). The histopathological severity and the incidence of uterine disease were higher among AGC women aged 40 years and older than those younger than 40 years ( p < .05). The possibility of the abnormal origin of glandular epithelial was higher than that of squamous epithelial in AGC patients aged 40 years and older ( p = .0003).

CONCLUSIONS

The management of AGC women by age triage is reasonable because the incidence of the glandular epithelial lesion and uterine disease increases in AGC patients 40 years or older. Standardized clinical diagnosis and regular follow-up are recommended for all AGC patients.

2023 Canadian Colposcopy Guideline: A Risk-Based Approach to Management and Surveillance of Cervical Dysplasia

This guideline provides evidence-based guidance on the risk-based management of cervical dysplasia in the colposcopy setting in the context of primary HPV-based screening and HPV testing in colposcopy. Colposcopy management of special populations is also discussed. The guideline was developed by a working group in collaboration with the Gynecologic Oncology Society of Canada (GOC), Society of Colposcopists of Canada (SCC) and the Canadian Partnership Against Cancer (CPAC). The literature informing these guidelines was obtained through a systematic review of the relevant literature via a multi-step search process led by information specialists. The literature was reviewed up to June 2021 with manual searches of relevant national guidelines and more recent publications. Quality of the evidence and strength of recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The intended users of this guideline include gynecologists, colposcopists, screening programs and healthcare facilities. Implementation of the recommendations is intended to promote equitable and standardized care for all people undergoing colposcopy in Canada. The risk-based approach aims to improve personalized care and reduce over-/under-treatment in colposcopy.

Clinicopathological features of atypical glandular cells, not otherwise specified, on cervicovaginal pap smears

OBJECTIVE

The Papanicolaou (Pap) smear test is a standard screening test that detects cervical lesions and cancers. In this multicentric study, we performed a retrospective analysis of cytological results associated with atypical glandular cells, not otherwise specified (AGC-NOS).

METHODS

We retrospectively reviewed Pap smear tests that resulted as AGC-NOS. A total of 254 women who underwent colposcopy due to a Pap smear result of AGC-NOS were included the study between 2003 and 2021. The ages, Pap smear results, HPV results if any, colposcopic biopsy results, endocervical and endometrial pathology results, and management of these patients were analysed.

RESULTS

Two hundred fifty-four patients with AGC-NOS Pap smear results were included in the study. A total of 70 (27.6%) patients had cervical and endometrial premalignant or malignant lesions. Malignancy was observed in 17 (6.7%) patients (endometrium, n = 11 [4.3%]; cervix, n = 6 [2.4%]). Isolated premalignant or malignant lesions of the cervix and endometrium were detected in 57 (22.4%) and 12 (4.7%) patients, respectively.

CONCLUSIONS

Patients diagnosed with AGC-NOS should undergo a careful evaluation with all clinicopathological features. Because cancer of the cervix and endometrium is not rare in patients diagnosed with AGC-NOS, colposcopic examination with endocervical sampling should be a priority based on a cervicovaginal smear. Endometrial sampling is also required according to the patient's clinic, age, and examination characteristics.

Conservative Treatment for Cervical Adenocarcinoma In Situ: Long-Term Results

OBJECTIVE

This study aimed to evaluate the effectiveness of conservative treatment for cervical adenocarcinoma in situ (AIS).

MATERIALS AND METHODS

This is a retrospective study on women with histologically confirmed AIS on cervical loop electrosurgical excision procedure specimen, treated conservatively between 2008 and 2020 in our center, Ospedale Maggiore Policlinico, Milan. The main outcome investigated was the risk of recurrence defined as a subsequent finding of recurrent AIS or invasive adenocarcinoma in a long-term follow-up. The disease-free survival curve was computed using the Kaplan-Meyer method. All patients underwent colposcopy with endocervical curettage and cytology every 6 months for the first 2 years after initial surgery and then annual cytology.

RESULTS

Thirty women, aged 26 to 51 years, with histologically proven AIS on excisional specimen with negative margins, negative apex, and negative endocervical curettage were included. The median follow-up was 5.4 years. One woman had a recurrence of AIS after 8 years of follow-up and underwent total hysterectomy. No invasive cervical disease was detected during surveillance.

CONCLUSIONS

Women with cervical AIS can be managed conservatively by an excisional procedure, provided that the margins are free and a close and long-term follow-up is guaranteed.

Cytological features of ovarian or tubal high-grade serous carcinoma: A retrospective study of 12 cases with abnormal cervical liquid-based smear

BACKGROUND

High-grade serous carcinoma (HGSC) is the most common epithelial carcinoma of the tubo-ovarian region, with a poor prognosis, which presents with an advanced stage at the time of diagnosis. This study summarizes the cytological features of cervical liquid-based cytological examination in order to diagnose ovarian or tubal HGSC at an early stage by cervical cytology smear.

METHODS

A total of 12 patients who were diagnosed with atypical glandular cell (AGC) and above lesions by cervical cytological examination and ovarian or tubal HGSC by histopathology were enrolled in this study. The cytological characteristics, including the arrangement and shape of the neoplastic cells, nuclear and cytoplasmic features, and the presence of tumor diathesis were reviewed.

RESULTS

Nine cases were determined to be AGC, and three cases were determined to be AGC favor neoplastic (AGC-FN) in the 12 cervical cytological diagnoses. The glandular cells showed significant atypia and proliferated actively with a three-dimensional structure. Increased nuclear-to-cytoplasmic ratios, prominent nucleoli, and hyperchromasia were common. Vacuole-like changes were observed in the cytoplasm. Tumor diathesis was observed in only one case (1/12, 8.30%).

CONCLUSION

Ovarian or tubal HGSC can occasionally be detected using cervical liquid-based cytology. It has distinct cytological characteristics. Primary ovarian or tubal HGSC with positive cervical cytology was accompanied by tumor cells in ascites, which suggested that the patient had progressed to an advanced stage.

High-Risk Human Papillomavirus Testing, Genotyping, and Histopathologic Follow-up in Women With Abnormal Glandular Cells on Papanicolaou Tests

OBJECTIVES

This study examined the association of high-risk human papillomavirus (hrHPV) status and HPV genotype with histopathologic follow-ups in women with an atypical glandular cell (AGC) interpretation.

METHODS

Cases with AGC interpretation on a Papanicolaou (Pap) test were retrieved along with hrHPV testing, genotyping, and histologic follow-up results if available.

RESULTS

A total of 561 AGC cases were identified, with histologic follow-up available for 471 cases (84%). The follow-up diagnoses included benign or reactive changes (60% of cases), low-grade cervical intraepithelial neoplasia (18%), high-grade cervical intraepithelial neoplasia (CIN2-3; 7%), cervical carcinoma (5%), and other malignancies (10%). Tests for hrHPV were positive in 128 of 426 (30%) cases, including HPV16 (30%), HPV18 (14%) and other HPV subtypes (56%). A positive hrHPV result significantly increased the risk of developing CIN2-3 or cervical carcinoma (odds ratio, 24.6; 95% CI, 9.9-58.9) and HPV16 or HPV18 further increased the risk (odds ratio, 49.5; 95% CI, 17.7-123.7).

CONCLUSIONS

Our data demonstrate that in women with an AGC Pap interpretation, a positive hrHPV result, especially type 16 or 18, is associated with an increased risk of developing cervical CIN2-3 or higher lesions, suggesting potential implications of hrHPV testing for the management of patients with an AGC result on a Pap test.

Do High Rates of Atypical Glandular Cells Correlate With Higher Incidence of Disease in a Large Safety Net Hospital

OBJECTIVE

The aim of the study was to describe the incidence and correlates of atypical glandular cell (AGC) Pap tests in a low socioeconomic status, underserved population.

MATERIALS AND METHODS

Medical records of patients with AGC Pap tests at a single institution were reviewed from January 2013 to August 2019. Baseline characteristics were extracted including age, body mass index, birth control, abnormal uterine bleeding, and human papillomavirus (HPV). All colposcopy and endometrial biopsies were classified into negative/low-risk (polyps, tubular metaplasia, microglandular hyperplasia, cervical intraepithelial neoplasia 1) and high-risk (HR) lesions (cervical intraepithelial neoplasia 2/3, adenocarcinoma in situ, endometrial hyperplasia, cervical cancer, endometrial cancer). Logistic regression identified significant associations. Sixty-eight randomly selected AGC cytology slides from the cohort and 32 non-AGC slides outside the cohort were blindly reviewed by 6 pathologists. Fleiss κ interrater agreement was assessed.

RESULTS

Seven hundred forty patients with AGC Pap tests were identified (0.8% of all Pap tests performed during this time). After excluding for incomplete data, 478 patients were included. Sixty-three patients had HR lesions (13.3%). Patients with HR lesions had increased odds of abnormal uterine bleeding (odds ratio = 4.32, p < .001) and HPV positivity (odds ratio = 10.89, p < .001) when compared with patients with low-risk lesions. The κ agreement was 0.21 for all cases and 0.18 for AGC alone.

CONCLUSIONS

This population falls within the national averages for AGC Pap tests. There was an increased risk of HR lesions in patients with abnormal uterine bleeding and HPV positivity. The rate of HR lesions among AGC Pap tests was at the lower end of values in the literature. After blinded pathologist review, interobserver κ agreement was low for AGC Pap tests.

Coexisting cancers with atypical glandular abnormalities by liquid-based cytology: A retrospective study in tertiary hospital in a high cervical cancer incident country

OBJECTIVE

To determine the incidence of coexisting cancers in women with glandular cell abnormalities detected from liquid-based cytology and to compare the detection rate of premalignant and malignant lesions among various subtypes of glandular cell abnormalities.

MATERIALS AND METHODS

From January 2014 to December 2016, liquid-based cytology was performed in 85,517 women. Using the Bethesda system 2001 criteria, abnormal cervical cytology was diagnosed in 3650 women (4.3%). Glandular cell abnormalities were diagnosed in 110 women (0.13%). Ten women with pre-existing genital tract cancers and 13 women who lost to follow up were excluded. Clinical characteristic, colposcopic finding, and histopathological data were reviewed in 87 women.

RESULTS

High-grade premalignant and malignant lesions were diagnosed in 34 patients (39.1%). Co-existing cancer was diagnosed in 31 patients (35.6%); 15 cervical cancers (17.2%) and 16 endometrial cancers (18.4%). The detection rate of significant lesions (CIN2+ or malignant lesions) in patients with AGC-NOS was 14.9%, AGC-FN was 38.9% and AIS/adenocarcinoma was 90.9% (p < 0.001).

CONCLUSION

Glandular cell abnormalities associated with high incidence of coexisting endometrial and cervical cancers. Comprehensive genital tract screening to evaluate gynecologic malignancy is strongly recommended in all women with glandular cell abnormalities.

Cervical glandular neoplasia referrals and the diagnosis of adenocarcinoma in situ: Correlating cytology, colposcopy findings, and clinical outcomes

OBJECTIVES

To determine the clinical outcomes of women with possible glandular neoplasia of endocervical type on cervical cytology, and review all diagnoses of cervical adenocarcinoma in situ (AIS) over a 5 year period at our institution.

STUDY DESIGN

A retrospective case-note review was conducted of all women referred to colposcopy with possible glandular neoplasia of endocervical type on cervical cytology or diagnosed with cervical AIS after biopsy or excision, from January 2014 until December 2018 in a London district hospital.

RESULTS

Of 55 women referred with possible glandular neoplasia of endocervical type, 47 (85.4%) had a significant pathology on histopathological analysis: AIS (n = 22); invasive cancer (n = 7); high-grade cervical intraepithelial neoplasia (n = 18). Women with a history of borderline abnormality on cervical cytology within the last 5 years were significantly more likely to be diagnosed with AIS or invasive cancer (P < .05). For the same period 49 women had histologically proven AIS. Among these 22 (44.8%) were referred as possible cervical glandular intraepithelial neoplasia. Other reasons for referral were the following indications: borderline dyskaryosis (n = 13); high-grade dyskaryosis (n = 8); low-grade dyskaryosis (n = 4); postcoital bleeding (n = 2).

CONCLUSION

Due to the raised risk of significant gynaecological pathology in women with possible glandular neoplasia of endocervical type on cervical cytology, excisional biopsy is essential. Colposcopic impression varies significantly and complete excision of the abnormal lesions should be achieved. AIS is a histological diagnosis and should always be considered during colposcopical and cytopathological assessment.

An audit of liquid-based cytology samples reported as high-risk human papillomavirus and borderline nuclear change in endocervical cells

INTRODUCTION

Primary human papillomavirus (HPV) screening, testing for the virus responsible for 99% of cervical cancers, was introduced in 2018-2020 in the UK. This was preceded by HPV triage of low-grade cytology from 2012. Much of the evidence incorporated into current National Health Service (NHS) colposcopy guidance assessed outcomes prior to this change in screening. The aim of this paper is to assess adherence to NHS cervical screening programme standards, determine the incidence of cases reported as high-risk HPV plus borderline nuclear change in endocervical cells, to calculate colposcopic accuracy and assess histological outcomes in this cohort.

METHOD

A retrospective audit of women referred to a colposcopy clinic in one NHS trust from 2016 to 2018. Data relating to histological outcomes, cytological follow-up and demographics were collected.

RESULTS

Of 2001 referrals, 22 data sets identifying HPV-positive borderline endocervical change were eligible for analysis (1.2% incidence). Median age was 29.5. Two-thirds (68.2%, n = 15) had high-grade dysplasia at diagnostic biopsy. Those women with reassuring histology had normal cytological follow-up. Colposcopic accuracy was moderate (positive predictive value 43.8%, negative predictive value 100%).

CONCLUSIONS

Borderline nuclear change in endocervical cells is an uncommon condition but should be treated as a high-grade referral. All women should be offered a diagnostic biopsy at the initial colposcopy; if no histopathological abnormality is identified, alternative sources of pathology should be considered. Excisional treatment should be recommended to unreliable attenders, those with a complete family and inadequate colposcopy (TZ3) and considered in younger women with a TZ3.

The relationship of human papillomavirus and cytology co-testing results with endometrial and ovarian cancer diagnoses

BACKGROUND

To investigate whether routine cervical screening using human papillomavirus (HPV) and cytology co-testing effectively identifies women with endometrial (EC) or ovarian (OvC) cancer.

METHODS

In 2003, Kaiser Permanente Northern California implemented triennial co-testing in women aged ≥30 years. Index screening results (n = 2,385,729) were linked to subsequent EC (n = 3434) and OvC (n = 1113) diagnoses from January 1, 2003 to December 31, 2017. EC were categorized as type 1 or 2, and, selectively, EC and OvC diagnoses were stratified on whether symptoms were present at the time of the co-test. Fractions and absolute risks of EC or OvC of each co-testing result were calculated.

RESULTS

Most EC (82.18%) and OvC (88.68%) were preceded by a negative HPV and negative cytology co-test. More EC were preceded by atypical squamous cells of undetermined significance (ASC-US) or more severe (ASC-US+) cytology and negative HPV test (n = 290) (8.44% of EC) compared to a negative cytology and a positive HPV test (n = 31) (0.89% of EC) (p < 0.001). The absolute risk of any EC diagnosis following ASC-US+ and negative HPV test was 0.48%. Atypical glandular cells (AGC) cytology and a negative HPV result preceded 6.92% of any EC diagnosis, with an absolute risk of 4.02%, but preceded only 1.13% of type 2 EC cases, with an absolute risk of 0.24%, in asymptomatic women. AGC cytology and a negative HPV result preceded 1.44% of OvC, with an absolute risk of 0.28%.

CONCLUSIONS

Abnormal cervical screening tests, even AGC cytology, rarely precedes and poorly predict women with EC or OvC.

Risk of Gynecologic Cancer after Atypical Glandular Cells Found on Cervical Cytology: A Population-Based Cohort Study

BACKGROUND

Atypical glandular cells (AGC) are rare abnormalities found on cervical cytology associated with a range of lesions of the female reproductive system. We compared the risk of cervical and other gynecologic cancers following AGC on cervical cytology with the risk following squamous cell abnormalities of comparable severity.

METHODS

We used data from the Dutch Pathology Archive (PALGA) from 2000 to 2015 to categorize cervical cytology tests into groups based on most severe cytologic abnormality and correlated follow-up advice (normal cytology and "no follow-up" advice, squamous-cell-based, AGC-based, and combined AGC/squamous-cell based each with either repeat testing or referral advice). Cancer data were linked from the Netherlands Cancer Registry. Cox proportional hazard models were calculated stratified by age [younger (<50 years) and older (50+ years)], adjusted for number of previous primary cytology tests.

RESULTS

8,537,385 cytology smears and 9,061 cancers were included. When repeat cytology testing was advised, HRs of cervical cancer (younger women: HR, 6.91; 95% CI, 5.48-8.71; older women: HR, 3.98; 95% CI, 2.38-6.66) or other gynecologic cancer diagnosis in younger women (HR, 2.82; 95% CI, 1.39-5.74) were significantly higher after an AGC-based abnormality compared with squamous-based abnormalities. Hazards were also significantly higher for "referral" advice cytology, except for cervical cancer among older women (HR, 0.88; 95% CI, 0.63-1.21).

CONCLUSIONS

AGC indicates an increased risk of gynecologic cancer compared with squamous-based abnormalities of comparable severity.

IMPACT

Gynecologists should be alert for cervical and endometrial cancers when examining women referred following AGC.

Trend analysis of process quality indicators for the Korean National Cervical Cancer Screening Program from 2005 to 2013

Objective

This study sought to examine changes in trends for quality indicators of the population-based Korean National Cancer Screening Program (KNCSP) for cervical cancer from years 2005 to 2013.

Methods

Our study data were derived from the KNCSP database. Cervical cancer diagnosis information was ascertained through linkage with the Korean National Cancer Registry and the KNCSP database. Performance measures for cervical cancer screening were estimated, including participation rate, positive rate, crude detection rate (CDR), interval cancer rate (ICR), positive predictive value (PPV), sensitivity, and specificity. Joinpoint analysis was applied to calculate annual percentage changes (APCs) in all indicators according to socio-demographic factors.

Results

A significant increasing trend was noted in participation rates (APC=13.4%; 95% confidence interval [CI]=10.5, 16.4). PPV and specificity increased from years 2005 to 2009 and remained stable till 2013. An increasing trend was discovered in CDRs for cervical cancer in situ (APC=3.9%; 95% CI=1.0, 6.9), whereas a decreasing trend was observed in ICRs for invasive cervical cancer (APC=−2.5%; 95% CI=−4.5, −0.5). Medical Aid recipients and women older than 70 years showed the lowest participation rates, but higher CDRs and ICRs, compared to other groups. In general, most of the quality indicators for cervical cancer screening improved from 2005 to 2009 and remained stable to 2013.

Conclusion

The KNCSP for cervical cancer in Korea has improved in terms of participation rate and accuracy of the screening test. These results may be attributed to the National Quality Improvement Program for KNCSP.

Diagnosis and Management of Adenocarcinoma in Situ: A Society of Gynecologic Oncology Evidence-Based Review and Recommendations

Cervical adenocarcinoma in situ is a unique diagnosis whose management needs to be differentiated from the management of the more prevalent squamous cell dysplasia.

This publication represents an extensive literature review with the goal of providing guidelines for the evaluation and management of cervical adenocarcinoma in situ (AIS). The authors drafted the guidelines on behalf of the Society of Gynecologic Oncology, and the guidelines have been reviewed and endorsed by the ASCCP. These guidelines harmonize with the ASCCP Risk-Based Management Consensus Guidelines and provide more specific guidance beyond that provided by the ASCCP guidelines. Examples of updates include recommendations to optimize the diagnostic excisional specimen, AIS management in the setting of positive compared with negative margins on the excisional specimen, surveillance and definitive management after fertility-sparing treatment, and management of AIS in pregnancy. The increasing incidence of AIS, its association with human papillomavirus–18 infection, challenges in diagnosis owing to frequent origin within the endocervical canal, and the possibility of skip lesions all make AIS a unique diagnosis whose management needs to be differentiated from the management of the more prevalent squamous cell dysplasia.

Implementation of primary HPV testing in Japan

Cervical cancer screening has been shifting from primary cytology to primary HPV testing worldwide as primary HPV testing is more sensitive than primary cytology. To the best of our knowledge, the current study is the first in Japan to examine the feasibility of primary HPV testing. One of the disadvantages of this shift is that hrHPV-/≥LSIL/CIN2+ (high-risk HPV negative cancers or pre-cancerous lesions with abnormal cytology results) can be missed. The objectives of the present study are to clarify in detail CIN2+ missed by this shift and to evaluate the feasibility of primary HPV testing in Japan. Data from 115,273 women who underwent co-testing with cytology and HPV testing in cancer screening were used in the current study. The cases with hrHPV-/≥LSIL (‘hrHPV-/≥L-SIL’ include CIN2-, in contrast, ‘hrHPV-/≥L-SIL/CIN2+’ doesn't include CIN2-) were analysed in detail. Women with hrHPV-/≥LSIL comprised 0.3% of the total. The prevalence of CIN2, CIN3, SCC or cervical adenocarcinomas in the lesions with HPV-/≥LSIL was 0.03% in the cancer screening group. Only one case of 14 cervical adenocarcinomas in ≥LSIL was hrHPV-. The prevalence of cancer missed by the shift in patients >50 years of age was significantly higher compared with patients younger than 49 years. In conclusion, the prevalence of CIN2+, which might be missed by the shift from primary cytology to primary HPV testing, was remarkably low in this Japanese cancer screening. The data indicated that primary HPV testing, which was more sensitive for CIN2+ than primary cytology, was a feasible method that can be used in Japan. In particular, primary HPV testing should be introduced for women <50 years old.

Subcategorization of atypical glandular cells is useful to identify lesion site

BACKGROUND

In the subcategorization of atypical glandular cells (AGCs), origin of cells should be mentioned to estimate lesion sites for diagnosis. However, cases without subcategorization are often encountered due to limited reproducibility. We evaluated whether the subcategorization of AGC based on the Bethesda terminology can estimate lesion sites.

METHODS

We retrospectively investigated cases whose cervical smears were interpreted as AGC and underwent pathological assessment at our institution between June 2009 and September 2017. AGC was subcategorized based on the Bethesda System. Not-otherwise-specified (NOS) was subcategorized into endocervical cells (NOS-EC), endometrial cells (NOS-EM), or glandular cells (NOS-G). Favor neoplastic (FN) was subcategorized into endocervical cells (FN-EC) or glandular cells (FN-G). FN-G was further subcategorized into endometrial cells (FN-EM) or unknown origin (FN-UO). Clinicopathological data were retrieved from the medical records.

RESULTS

Of 88 AGC cases, there were 30 NOS-EC (34.1%), 2 NOS-EM (2.3%), 25 FN-EC (28.4%), 22 FN-EM (25.0%), and 9 FN-UO (10.2%). A significantly higher proportion of neoplastic lesions occurred in FN than in NOS (P <.001). The concordance of AGC subclass and lesion site was 88.0%, 70.7%, and 77.3% in FN-EC, FN-G, and FN-EM, respectively. The concordance of FN-EM and lesion site increased to 88.9% in patients aged >50 years. Of nine cases of FN-UO, six experienced nonendometrioid endometrial cancer and extrauterine malignancy.

CONCLUSION

Subcategorization of NOS and FN would be useful in estimating neoplastic lesions. Further subcategorization into FN-EC, FN-EM, and FN-UO would similarly be beneficial in estimating the lesion site, especially for small endometrial and extrauterine lesions.

Screening and management of preinvasive lesions of the cervix: Good clinical practice recommendations from the Federation of Obstetrics and Gynaecologic Societies of India (FOGSI)

In India, there are marked variations in resources for cervical cancer screening. For the first time, resource-stratified screening guidelines have been developed that will be suitable for low middle-income countries with similar diversities. The current article describes the process and outcomes of these resource stratified guidelines for screening and treatment of preinvasive lesions of cervix. Evidence from literature was collated and various guidelines were reviewed by an expert panel. Based on the level of evidence, guidelines were developed for screening by human papillomavirus (HPV) testing, cytology and visual inspection after application of acetic acid (VIA), and management of screen positive lesions in different resource settings. Expert opinion was used for certain country-specific situations. The healthcare system was stratified into two resource settings - good or limited. The mode of screening and treatment for each was described. HPV testing is the preferred method for cervical cancer screening. VIA by trained providers is especially suitable for low resource settings until an affordable HPV test becomes available. Healthcare providers can choose the most appropriate screening and treatment modality. A single visit approach is encouraged and treatment may be offered based on colposcopy diagnosis ('see and treat') or even on the basis of HPV test or VIA results ('screen and treat'), if compliance cannot be ensured. The Federation of Obsterician and Gynaecologists of India Good Clinical Practice Recommendations (FOGSI) GCPR are appropriately designed for countries with varied resource situations to ensure an acceptable cervical cancer prevention strategy.

Atypical glandular lesions of the cervix and risk of cervical cancer

INTRODUCTION

Cytology screening has been effective in reducing risks for cervical squamous cell carcinoma but less so for adenocarcinoma. We explored the association of atypical glandular cells or absence of glandular cells in cytology, and subsequent histological diagnoses and cancer risk.

MATERIAL AND METHODS

All women in Norway with atypical glandular cells of undetermined significance (AGUS), adenocarcinoma in situ (ACIS) and normal/benign cells, but absence of endocervical or metaplastic cells (NC-NEC) in their first cytology during 1992-2014 (NC-NEC; 2005-2014), recorded in the Cancer Registry of Norway, were included (n = 142 445). Histology diagnoses (stratified by age) within 1 and 3 years after cytology were examined. The Nelson-Aalen cumulative hazard function for gynecological cancer risk was displayed.

RESULTS

The majority of AGUS and particularly ACIS were followed with histology within 1 and 3 years. Cervical intraepithelial neoplasia (CIN) lesions were more common in women <35 than in women ≥35 years. Cervical adenocarcinoma followed 13% of ACIS after 1 and 3 years. After ACIS and AGUS, cervical adenocarcinoma was the most frequent cancer subtype. Cumulative risks of cervical adenocarcinoma following ACIS, AGUS and NC-NEC were 3.5%, 0.9% and 0.05%, respectively, after 22, 22 and 9 years of follow-up.

CONCLUSIONS

There was a high-risk of glandular malignancies after AGUS and ACIS in cytology. If effective treatment of pre-cancer and early cancer is available, cytology screening provides some level of prevention of adenocarcinoma. Lack of glandular cells did not entail a higher cancer risk.

Reappraisal of cytology-histology correlation in cervical cytology based on the recent American Society of Cytopathology guidelines (2017) at a cancer research centre

OBJECTIVE

To assess the impact of recently published American Society of Cytopathology (ASC) guidelines (2017) on the conduct of cervical cytology-histology correlation (CHC).

METHODS

A retrospective review was conducted for cervical biopsies with their corresponding conventional cervical smears over a 7.5-year period (January 2011-June 2018). As per the ASC guidelines, a discrepancy assessment grid was prepared. Major cytology-histology discordance was defined as a diagnosis of high-grade squamous intraepithelial lesion (HSIL) or CIN2+ in one of the tests with negative result in the other. Smears and biopsies of all discordant cases were reviewed for reasons of overcall and undercall.

RESULTS

Of the 341 cervical biopsies with corresponding Papanicolaou smear, cytology-histology agreement was noted in 249 (73%) cases. Major discordance was observed in 22 cases (6.4%)-16 undercalls and six overcalls on cytology-while minor discrepancies were noted in 70 cases. Atypical metaplasia and repair changes were the main reasons for overcall while small HSIL cells in atrophic smear and scant HSIL cells were important causes of undercall on cytology review. Using the ASC guidelines, we could improvise upon the existing CHC methodology for categorisation of cyto-histological pairs of cases with a cytological diagnosis of atypical glandular cells.

CONCLUSION

The present study demonstrates, for the first time, that the recent ASC guidelines facilitate cervical CHC, especially for categorisation of cases with atypical glandular cells on cytology. Uniform application of these guidelines would standardise the conduct of cervical CHC internationally and provide scope for inter-laboratory comparison of data as well as enhance self-learning and peer learning.

Evaluation of liquid from the Papanicolaou test and other liquid biopsies for the detection of endometrial and ovarian cancers

We report the detection of endometrial and ovarian cancers based on genetic analyses of DNA recovered from the fluids obtained during a routine Papanicolaou (Pap) test. The new test, called PapSEEK, incorporates assays for mutations in 18 genes as well as an assay for aneuploidy. In Pap brush samples from 382 endometrial cancer patients, 81% [95% confidence interval (CI), 77 to 85%] were positive, including 78% of patients with early-stage disease. The sensitivity in 245 ovarian cancer patients was 33% (95% CI, 27 to 39%), including 34% of patients with early-stage disease. In contrast, only 1.4% of 714 women without cancer had positive Pap brush samples (specificity, ~99%). Next, we showed that intrauterine sampling with a Tao brush increased the detection of malignancy over endocervical sampling with a Pap brush: 93% of 123 (95% CI, 87 to 97%) patients with endometrial cancer and 45% of 51 (95% CI, 31 to 60%) patients with ovarian cancer were positive, whereas none of the samples from 125 women without cancer were positive (specificity, 100%). Finally, in 83 ovarian cancer patients in whom plasma was available, circulating tumor DNA was found in 43% of patients (95% CI, 33 to 55%). When plasma and Pap brush samples were both tested, the sensitivity for ovarian cancer increased to 63% (95% CI, 51 to 73%). These results demonstrate the potential of mutation-based diagnostics to detect gynecologic cancers at a stage when they are more likely to be curable.

Significance of atypical endometrial cells in women younger than 40 years of age

INTRODUCTION

The presence of atypical endometrial cells in the Papanicolaou (Pap) test has been associated with an increased rate of endometrial malignancy, with reported rates ranging from 14% to 47%. However, most reported studies have focused on patients who were aged >40 years. The purpose of the present study was to investigate the clinical significance of identifying atypical endometrial cells in Pap test samples in women aged <40 years of age.

MATERIALS AND METHODS

A search of the cytology Pap test database was performed from 2000 to 2014 using the keywords "atypical endometrial cells" or "atypical glandular cells favor endometrial origin" in women aged <40 years. The available ThinPrep slides were reviewed. The patients' clinical presentation, follow-up endometrial biopsy findings, treatment, and clinical follow-up data were recorded. Endometrial carcinoma tissue sections were screened for Lynch syndrome.

RESULTS

The database search yielded 63 study cases. Of these 63 patients, 52 had subsequently undergone endometrial biopsy. Of the 52 patients with follow-up biopsy findings available, 9 (17.3%) had premalignant (5 with atypical hyperplasia) or malignant (4 with endometrioid adenocarcinoma) lesions. In addition, 16 patients (30.8%) had other endometrial pathologic features. The 9 patients with premalignant or malignant endometrial lesions (8 white, 1 black) were overweight or obese; 3 of the patients did not have any clinical symptoms. All 4 patients with endometrioid adenocarcinoma had negative Lynch syndrome screening findings.

CONCLUSIONS

Our results suggest that it is important to recognize the presence of atypical endometrial cells in the Pap tests from young patients, given its association with the finding of premalignant and malignant pathologic features in subsequent endometrial biopsies.

[Use of HPV virologic test for atypical glandular cells in Alsace between 2014 and 2016]

OBJECTIVES

The new recommendations by the National Institute of Cancer (January 2017) recommend the use of a complementary human papillomavirus (HPV) virologic test during the diagnosis of atypical glandular cells in pap smear. The aim of this study was the performance analysis of the HPV virologic test for the detection of significant histological cervical abnormalities (CIN2 or more) in case of atypical glandular cells before the new recommendations were published.

METHODS

We performed a descriptive and retrospective cohort study in Alsace between January 2014 and December 2016. We have included, from the EVE-association database, the patients with atypical glandular cells in pap smear.

RESULTS

In total, 1074 patients had a pap smear with atypical glandular cells ; 0.18% of total pap smears. This study included 152 patients who had a HPV test. We observed 6 cases of CIN2 (3.9%) and 12 cases of CIN3 (7.9%). No in situ adenocarcinoma nor invasive carcinoma were detected. The sensitivity of the HPV test was 88.9% (95% CI: [0.65; 0.99]), the specificity was 65.9% (95% CI: [0.55; 0.76]), the positive predictive value was 34% (95% CI: [0.21; 0.49]) and the negative predictive value was 96.8% (95% CI: [0.89; 0.99]).

CONCLUSION

The detection of HPV in atypical glandular cells seems to be powerful with an excellent negative predictive value but, because of moderate sensitivity and due to the risk of histologic lesion progression, the current recommendations should to be applied with care.

Adenocarcinoma in situ of the uterine cervix: Clinical practice guidelines from the Italian society of colposcopy and cervical pathology (SICPCV)

OBJECTIVE

to provide a practical tool for the evidenced-based management of adenocarcinoma in situ (AIS) of the uterine cervix, a challenging diagnosis encountered by colposcopists in their daily practice.

METHODS

the proposed recommendations were drafted by the Italian Society of Colposcopy and Cervical Pathology (SICPCV) based on comprehensive reviews of previous guidelines, large uncontrolled studies, metanalysis, and sytematic reviews. The quality Level and the strength of the recommendations were graded and respectively expressed in Roman numbers (I-VI) and letters (A-E).

RESULTS

Women with all subcategories of abnormal glandular cells and AIS on cervical citology should be offered colposcopy with endocervical sampling (Strength of recommendation: A). In women with cytological AIS and negative colposcopy or endocervical curettage, an excisional treatment under colposcopic guidance is recommended (Strength of recommendation: A). If immediate post-conization endocervical sampling is positive, further conization is indicated (Strength of recommendation: C). In women who desire to preserve fertility with positive cone margins, further conization should be performed (Strength of recommendation: B). If colposcopy is adequate, a cylindrical excision that includes the whole transformation zone and at least 1-1.5 cm of endocervix beyond the squamous-columnar junction should be performed (Strength of recommendation: B). If colposcopy is inadequate, it is recommended that conization includes the whole transformation zone with a depth of 20-25 mm (Strength of recommendation: B). Hysterectomy is the standard definitive treatment for AIS in women who do not wish to preserve fertility (Strength of recommendation: B).

CONCLUSION

the proposed recommendations should enable clinicians to correctly diagnose, treat and follow AIS patients, avoiding mismanagement.

Clinicopathological Characteristics of Atypical Glandular Cells Determined by Cervical Cytology in Japan: Survey of Gynecologic Oncology Data from the Obstetrical Gynecological Society of Kinki District, Japan

BACKGROUND

The purpose of this study was to clarify the clinicopathological characteristics of, and the clinical approach used to identify, atypical glandular cells (AGCs) in Japan based on cervical cytology screening.

OBJECTIVES

This study included 1,254 patients with AGCs who underwent cervical cytology.

METHOD

Data from patients with AGCs were used to examine the practical management of AGCs and the histological results.

RESULTS

The incidence of AGCs was 0.20% (1,254/614,791). The 1,254 AGC cases included 859 endocervical cells not otherwise specified (NOS), 3 glandular cells NOS, 91 endocervical cells favor neoplasia (FN), and 301 atypical endometrial cells (AEMCs). Among the 1,254 AGC patients, the histological diagnosis was benign in 666 (53.1%), cervical intraepithelial neoplasia (CIN) 1 in 60 (4.8%), CIN2 in 31 (2.5%), CIN3 in 52 (4.1%), squamous cell carcinoma in 19 (1.5%), adenocarcinoma in situ in 39 (3.1%), cervical adenocarcinoma in 106 (8.5%), endometrial carcinoma in 209 (16.7%), ovarian cancer in 26 (2.1%), other malignancy in 4 (0.3%), and other under follow-up in 42 (3.3%). When the 1,254 AGC patients were divided into three medical intervention degrees according to histology, AGC-NOS, AGC-FN, and AEMC required no medical intervention in 78.7, 13.2, and 25.9% (678, 12, and 78) of the patients, cervical cone resection in 13.0, 9.9, and 0.3% (112, 9, and 1) of the patients, and radical laparotomy for invasive cancer in 8.3, 76.9, and 73.8% (72, 70, and 222) of the patients, respectively.

CONCLUSIONS

Our histological results supported the medical interventions applied for AGC diagnosis and treatment. AGC cases require careful histological evaluation.

The reporting rates of atypical glandular cells and their HPV testing and histologic follow-up results: a comparison between ThinPrep and SurePath preparations from a single academic institution

INTRODUCTION

The interpretation of atypical glandular cells (AGCs) remains a major challenge in gynecologic cytopathology using liquid-based cytology (LBC) (ThinPrep and SurePath). The comparison of performance of detecting glandular abnormalities using these 2 methods is lacking. We investigated the reporting rates of AGCs, human papillomavirus (HPV) testing, and histologic follow-up results in ThinPrep (TP) and SurePath (SP) samples.

MATERIALS AND METHODS

In our institution, both TP and SP were utilized during the period between January 2014 and June 2017. A retrospective search was conducted to identify patients with AGCs from 58,591 LBCs (27,041 TP and 31,550 SP). Roche (Pleasanton, CA) cobas HPV testing and histologic follow-up results were collected.

RESULTS

The reporting rates of AGCs for TP (0.7%) or SP (0.2%) were within the College of American Pathologists benchmark ranges, but the reporting for TP was significantly greater than that for SP (P < 0.0001). The HPV-positive rates were 26.0% and 19.4% in TP-AGCs and SP-AGCs, respectively, with no statistical significance. A total of 137 (74.9%) TP-AGCs and 54 (74%) SP-AGCs had histologic follow-up. High-grade squamous intraepithelial lesions (HSIL)/squamous cell carcinoma were identified in 8.8% (12 of 137) of TP-AGCs and 13% (7 of 54) of SP-AGCs. Adenocarcinomas including endocervical and endometrial adenocarcinomas were identified in 9.5% (13 of 137) of TP-AGCs and 13% (7 of 54) of SP-AGCs. Together, 18.2% (25 of 137) of TP-AGCs and 25.9% (14 of 54) of SP-AGCs showed either HSIL or carcinoma in histologic follow-up, but with no statistical significance.

CONCLUSIONS

TP preparation detected considerably more AGCs than SP preparation. There was no statistical significant difference in HPV-positive rates or histologic follow-up outcomes between TP-detected AGCs and SP-detected AGCs.

Cervical Screening Results Leading to Detection of Adenocarcinoma in Situ of the Uterine Cervix

Background: Adenocarcinoma in situ (AIS) of the uterine cervix is a preinvasive lesion of the invasive adenocarcinoma. We analyzed the cervical screening results leading to detecting the AIS lesions including the coexistence of AIS lesions with high-grade squamous intra-epithelial lesions (HSIL) and invasive carcinoma. Methods: Women who were diagnosed and received treatment for AIS at Chiang Mai University Hospital between January 1, 2007 and August 31, 2016 were retrospectively reviewed. The inclusion criteria were the women who had pathological diagnosis of AIS obtained from cervical punch biopsy or excisional cone biopsy with either loop electrosurgical excision procedure (LEEP) or cold-knife conization (CKC). The patient characteristics, diagnostic work-up and treatment details were reviewed, including the cervical screening results prior to the diagnosis of cervical AIS, pathologic results of excisional cone biopsy and hysterectomy specimens. Results: During the study period, 75 women with AIS pathology undergoing excisional cone biopsy with either LEEP (n=62) or CKC (n=13) were identified. The abnormal cytologic screening leading to detection of AIS was the squamous cell abnormality accounting for 57.3%. Abnormal glandular cytology accounted for 37.3%. The most common abnormal cervical screening results was HSIL cytology (n = 25) followed by AIS cytology (n = 13). Normal cytology was noted in 4 women in whom 3 were positive for HPV 18 and 1 had AIS on the endocervical polyp. AIS coexisted with HSIL and invasive carcinoma were detected in cone biopsy specimens in 21 (28%) and 29 (38.7%) patients, respectively. Conclusion: The majority of cervical screening results leading to detection of cervical AIS was the squamous cell abnormality accounting for 57.3% in which, HSIL cytology was the most common. Abnormal glandular cytology accounted for only 37.3%. Diagnostic cone excision is recommended if AIS lesion is noted in cervical biopsy specimen since nearly 40% have coexisting invasive lesions.

Evaluation of Clinicopathologic Features of Patients Diagnosed with Atypical Glandula Cells in Cervical Cytology

Objective

In our study we aimed to evaluate the clinicopathologic features of patients diagnosed with atyipcal glandular cells on cervical cytology.

Method

The records of 9375 patients who were examined in the gynecology outpatient clinic between 2010 and 2018 and underwent cervicovaginal smear were retrospectively reviewed. Seventy-three (0.8%) patients were diagnosed as atypical glandular cells. Colposcopic examination, cervical biopsy, endocervical and endometrial curettage were performed in patients diagnosed with atypical glandular cells. Age, gravida, parity, systemic diseases and clinicopathological features of the patients were examined and recorded.

Results

Cervical and endometrial abnormal histological findings were detected in 26 (35.6%) of 73 patients with atypical glandular cells. Of these 26 patients, 14 (19.1%) had cervical intraepithelial lesions, 3 (4.1%) had endometrial hyperplasia and 9 (12.3%) had invasive cancer. Five (6.8%) of the 9 patients with the diagnosis of invasive cancer had adenocarcinoma (endocervical and endometrial), in 3 (4.1%) patients cervical squamous carcinoma, and in 1 patient. endocervical lymphoma was observed.The majority of cancers detected in our study were in the age group of 50 years and older.

Conclusion

Invasive cancer is seen in 12.3% of the patients diagnosed with atypical glandular cells, and most of these patients are 50 years or older. Therefore patients diagnosed with atypical glandular cell in cervicovaginal smear should be carefully evaluated with all clinical features.

The feasibility of detecting endometrial and ovarian cancer using DNA methylation biomarkers in cervical scrapings

Objective

We hypothesized that DNA methylation of development-related genes may occur in endometrial cancer (EC)/ovarian cancer (OC) and may be detected in cervical scrapings.

Methods

We tested methylation status by quantitative methylation-specific polymerase chain reaction for 14 genes in DNA pools of endometrial and OC tissues. Tissues of EC/normal endometrium, OC/normal ovary, were verified in training set using cervical scrapings of 10 EC/10 OC patients and 10 controls, and further validated in the testing set using independent cervical scrapings in 30 EC/30 OC patients and 30 controls. We generated cutoff values of methylation index (M-index) from cervical scrapings to distinguish between cancer patients and control. Sensitivity/specificity of DNA methylation biomarkers in detecting EC and OC was calculated.

Results

Of 14 genes, 4 (PTGDR, HS3ST2, POU4F3, MAGI2) showed hypermethylation in EC and OC tissues, and were verified in training set. POU4F3 and MAGI2 exhibited hypermethylation in training set were validated in independent cases. The mean M-index of POU4F3 is 78.28 in EC and 20.36 in OC, which are higher than that in controls (6.59; p<0.001 and p=0.100, respectively), and that of MAGI2 is 246.0 in EC and 12.2 in OC, which is significantly higher that than in controls (2.85; p<0.001 and p=0.480, respectively). Sensitivity and specificity of POU4F3/MAGI2 were 83%–90% and 69%–75% for detection of EC, and 61% and 62%–69% for the detection of OC.

Conclusion

The findings demonstrate the potential of EC/OC detection through testing for DNA methylation in cervical scrapings.

Risk of high-grade lesions after atypical glandular cells in cervical screening: a population-based cohort study

OBJECTIVES

To determine how human papillomavirus (HPV) positivity of atypical glandular cells (AGCs) affects the predictive values for the presence of high-grade cervical lesions.

DESIGN

Population-based cohort study.

SETTING

Stockholm-Gotland region, Sweden.

PARTICIPANTS

Between 17 February 2014 and 30 June 2016, there were 562 women with AGC detected in a cervical sample. Registry linkages up to 30 June 2016 identified 392 women with an associated HPV test and a histopathological follow-up.

MAIN OUTCOME MEASURE

Presence of a high-grade cervical lesion in the cervical biopsy taken after the AGC smear, in relation to the HPV status of the AGC-containing index smear.

RESULTS

The proportion of HPV-positive AGC was 56% (n=222). In this group, there were six cases of invasive cervical adenocarcinoma, 33 cases of cervical adenocarcinoma in situ and 93 cases of high-grade squamous intraepithelial lesion (HSIL), giving a positive predictive value (PPV) for a cervical high-grade lesion of 60% (132/222). Among the 170 women with HPV-negative AGC, there was one invasive cervical squamous cell cancer and four HSIL, giving an PPV for a cervical high-grade lesion of 2.9% (5/170). This group also contained five endometrial cancers and one breast cancer.

CONCLUSIONS

HPV triaging of AGC will greatly increase the predictive ability for identifying cervical high-grade lesions (OR: 48.4 (95% CI 19.1 to122.6)) and the high sensitivity (96%; 132/137 women) implies safety of primary HPV screening strategies, with regard to this subset of patients. The measurable risk for endometrial cancer among women with HPV-negative AGC (2.9%) suggests that research on screening for endometrial cancer is needed.

Current strategies in the diagnosis of endometrial cancer

PURPOSE

Endometrial cancer is the most common gynecological malignancy in developed countries. There are no uniform recommendations for endometrial cancer screening in the general population. Therefore, it is of paramount importance that the primary physician profoundly understands, and is familiar with the methods for prevention and early detection of endometrial cancer. The aim of this review is to provide the primary physician with a toolbox to reach these goals.

METHODS

We performed a systemic review to summarize the current strategies to diagnose and prevent endometrial cancer. Many published articles from the last years were identified and included.

RESULTS

A systematic review that summarizes the important subjects in the diagnosis and prevention of endometrial cancer.

CONCLUSION

Maintaining a high index of suspicion and obtaining endometrial biopsies from all suspected patients is the key for achieving a timely diagnosis.

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

CONTEXT

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Clinical Behavior and Treatment of Endometrial Cancer

Endometrial cancer is the most common gynecologic malignancy diagnosed in women in the developed nations. It affects a disproportionate number of reproductive-aged women. While the overall prognosis is good compared to other cancers affecting women, the pathogenesis and clinical behavior of endometrial cancer are heterogeneous. The risk factors associated with the type I and type II endometrial cancers and their pathogenesis will be discussed, as well as the evaluation and primary treatment of women with endometrial cancer. The chapter will also focus on risk stratification for recurrence after surgery and role of adjuvant treatments. Finally, the treatment of recurrent endometrial cancer will be presented.

Histological Follow-Up in Patients with Atypical Glandular Cells on Pap Smears

Context:

Atypical glandular cells (AGCs) result in the Papanicolaou (Pap) smear may be associated with significant genital and nongenital neoplastic processes.

Aims:

To evaluate the underlying histopathology in women who had AGCs on Pap smears.

Settings and Design:

Retrospective cross-sectional study.

Patients and Methods:

Clinicopathological data of patients who had AGC on Pap smears and underwent histological workup between January 2004 and December 2014 were retrieved from the computerized database of a tertiary care center. Patients with a prior history of cervical intraepithelial neoplasia or gynecological cancer were excluded.

Statistical Analysis Used:

Chi-square test or Fisher's exact tests were used as appropriate.

Results:

Cytological examination of the uterine cervix was carried out in 117,560 patients. We identified 107 patients (0.09%) with AGC and 80 of those with histological follow-up were included in the study. The median age at diagnosis was 47 years (range, 18–79), and 32 women (40%) were postmenopausal, while 56 (70%) had gynecological symptoms. Significant preinvasive or invasive lesions on pathological examination were detected in 27 (33.8%) patients, including 12 endometrial adenocarcinomas (15%), 8 cervical carcinomas (10%), 3 cervical intraepithelial neoplasia II/III (3.75%), 2 ovarian adenocarcinomas (2.5%), and 2 metastatic tumors (2.5%). Univariate analysis showed that postmenopausal status (P < 0.001), age >50 years old (P < 0.001), having symptoms at the time of admission (P = 0.041), and AGC “favor neoplasia” smear results (P = 0.041) were the clinical factors associated with significant pathological outcome.

Conclusions:

Patients with AGC on Pap smears should be evaluated vigilantly with histological workup, especially if they are postmenopausal or symptomatic.