"Low-grade squamous intraepithelial lesion, cannot exclude high-grade squamous intraepithelial lesion" is a distinct cytologic category: histologic outcomes and HPV prevalence

We examined the histologic outcomes and prevalence of high-risk human papillomavirus (HR-HPV) in women with liquid-based Papanicolaou (Pap) tests interpreted as "low-grade squamous intraepithelial lesion, cannot exclude high-grade squamous intraepithelial lesion" (LSIL-H) compared with the 2001 Bethesda System (TBS 2001) cytologic categories of LSIL, high-grade SIL (HSIL), and atypical squamous cells, cannot exclude HSIL (ASC-H). A computer search identified 426 LSIL, 86 ASC-H, 81 LSIL-H, and 110 HSIL cytologic interpretations during a 1-year period, each with up to 2 years of histologic follow-up. The risk of histologic cervical intraepithelial neoplasia (CIN) 2 or worse (CIN 2+) associated with LSIL-H (32/81 [40%]) was intermediate between LSIL (46/426 [10.8%]) and HSIL (72/110 [65.5%]), but not significantly different from ASC-H (23/86 [27%]). However, LSIL-H was more frequently associated with a definitive histologic diagnosis of any CIN (CIN 1+) than ASC-H (53/81 [65%] vs 35/86 [41%]). Moreover, the prevalence of HR-HPV was significantly greater in patients with LSIL-H than in patients with ASC-H (15/15 [100%] vs 43/73 [59%]). The histologic outcomes and HR-HPV prevalence associated with LSIL-H differ significantly from the established categories of TBS 2001 and provide evidence to support the recognition of LSIL-H as a distinct cytologic category.     

Intermediate‐grade squamous intraepithelial lesion may be a valid diagnostic/interpretive category

We undertook this study to assess the characteristics of smears with features intermediate between high‐grade squamous intraepithelial lesion (HSIL) and low‐grade squamous intraepithelial lesion (ISIL). We also wanted to determine how these smears correlate with high risk biopsy diagnosis and to compare this with the biopsy correlation of LSIL and HSIL. Seventy‐four squamous intraepithelial lesion (SIL) smears were identified as intermediate‐grade SIL smears taken at colposcopy in a 1 year period. They were correlated with concurrent colposcopically guided biopsies. Thirty‐five percent of cases with intermediate‐grade SIL smears had a biopsy diagnosis of moderate dysplasia or higher as compared with 12% for LSIL 74% for HSIL. This confirmed our hypothesis that intermediate‐grade SIL smears have a rate of biopsy diagnosis of moderate dysplasia or higher intermediate to that of LSIL and HSIL. Diagn. Cytopathol. 2009. © 2008 Wiley‐Liss, Inc.     

Low-grade squamous intraepithelial lesion, cannot exclude high-grade squamous intraepithelial lesion: a category with an increased outcome of high-grade lesions: use as a quality assurance measure

"Low-grade squamous intraepithelial lesion (LSIL), cannot exclude high-grade squamous intraepithelial lesion" (LSIL-H) is an increasingly used, equivocal interpretive category in gynecologic cytology. In an effort to evaluate its potential usefulness as a measure of quality assurance, we studied patterns of use of the LSIL-H diagnosis compared with "LSIL" and "high-grade squamous intraepithelial lesion" (HSIL) with corresponding histologic outcomes for 10 cytopathologists in our practice. In our laboratory, while the overall rate of associated cervical intraepithelial neoplasia 2 or greater on histologic follow-up for LSIL-H was intermediate between that of LSIL and HSIL, the outcomes for individual cytopathologists varied widely. Monitoring this particular utilization-outcome data with periodic confidential feedback to individual cytopathologists offers an opportunity for practice improvement within a laboratory and serves as an additional measure of quality assurance. These data may be useful for establishing and/or realigning the diagnostic criteria for this equivocal cytologic interpretation endorsed by a pathology practice.     

高危型人乳头状瘤病毒检测在不除外高度鳞状上皮内病变的不典型鳞状上皮细胞中的意义

目的 探讨高危型人乳头状瘤病毒(HR-HPV)的检测在宫颈细胞学不除外高度鳞状上皮内病变的不典型鳞状上皮细胞(ASC-H)中的意义.方法 对45例诊断为ASC-H的患者用杂交捕获二代(HC-Ⅱ)方法检测HR-HPV DNA含量,并进行阴道镜检查及活检,分析其结果之间的关系.结果 45例ASC-H的活检结果为宫颈鳞状上皮内病变(SIL)33例(73.3%);45例ASC-H中36例HR-HPV阳性,其中高度鳞状上皮内病变(HSIL)及以上病变者19例(52.8%);9例HR-HPV阴性病例中,没有HSIL及以上病变;HR-HPV对ASC-H患者HSIL的敏感性及阴性预测值均为100%.结论 ASC-H高度提示宫颈病变的存在;HR-HPV可以作为ASC-H患者是否需要立即阴道镜检查的一个预测指标,HR-HPV阳性者应立即阴道镜检查及活检,HR-HPV阴性是HSIL阴性的一个预测指标.     

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. Diagn. Cytopathol. 2013;41:943–946. © 2013 Wiley Periodicals, Inc.     

CINtec® PLUS dual immunostain: A triage tool for cervical pap smears with atypical squamous cells of undetermined significance and low grade squamous intraepithelial lesion

ASC and LSIL comprise the majority of abnormal Pap smears. Currently, high‐risk human papillomavirus testing is utilized to triage women with ASC for colposcopy; however, no cost effective triage method is available for LSIL. p16 and Ki‐67 have each been shown to be good biomarkers for high grade cervical intraepithelial neoplasia (HG CIN).We evaluated the role of the CINtec® PLUS p16/Ki‐67 dual immunostain as a marker for underlying (U) or subsequent (S) HG CIN. One hundred and eighty eight cervical SurePath Pap smears with histological and/or cytological follow‐up were retrieved from our departmental files. The Pap stained slides were destained and then immunostained utilizing the CINtec® PLUS dual staining reagent kit. Results of the dual stain were correlated with follow‐up diagnoses. Sensitivity, specificity, and positive and negative predictive values of CINtec® PLUS for U or S HG CIN were compared with those of HR HPV testing and with p16 and Ki‐67 immunostaining alone. The sensitivity of CINtec® PLUS for U or S HG CIN was 91% in the ASC group and 100% in the LSIL group, while the corresponding specificities were 61 and 43%, respectively. The sensitivity and specificity of CINtec® PLUS for U or S HG CIN in both groups combined were 97 and 53%, respectively. CINtec® PLUS was more specific than HR HPV testing and Ki‐67 and p16 immunostains alone in detecting an U or S HG CIN. CINtec® PLUS is a helpful adjunct in identifying U or S HG CIN when applied to SurePath Pap smears with ASC or LSIL. Diagn. Cytopathol. 2013. © 2012 Wiley Periodicals, Inc.     

MMP‐9 expression increases according to the grade of squamous intraepithelial lesion in cervical smears

Studies about cervical carcinogenesis have demonstrated the increased expression of matrix‐metalloproteinase (MMP) according to the grade of cervical intraepithelial lesions. Considering the importance of innovative techniques to introduce noninvasive and rapid diagnoses for patients, this study aimed to perform MMP‐9 immunocytochemistry in cervical smears according to the cytopathological diagnoses, in order to monitor MMP activity in cervical smears. This cross‐sectional study investigated the expression of MMP‐9 in normal cervical smears, inflammatory cervical smears, squamous intraepithelial lesions, and cervical carcinoma. Cervical smears from 630 women were collected for cytopathological diagnoses and immunocytochemistry. Women with squamous intraepithelial lesions showed an increase in MMP‐9 expression, with moderate to intense staining occurring with increasing cervical lesion grade. The prevalence of moderate to intense MMP‐9 staining was 9% in normal cervical smears, 12% in cervical inflammation, 24% in low‐grade squamous intraepithelial lesion (LSIL), 92% in high‐grade squamous intraepithelial lesions (HSIL) and 100% in cervical carcinoma cases. In the specific case of LSIL, we found that association with MMP‐9 is more evident when there is the simultaneous presence of an infectious agent. Thus, the expression of MMP‐9 in cervical smears increases according to the grade of cervical lesion and LSIL in the presence of infectious agents showed higher MMP‐9 expression than women with LSIL without infectious agents. Diagn. Cytopathol. 2014;42:827–833. © 2014 Wiley Periodicals, Inc.     

Atypical squamous cells of undetermined significance--rule out high-grade squamous intraepithelial lesion: cytopathologic characteristics and clinical correlates

The significance and clinical management of atypical squamous cells of undetermined significance (ASCUS) on cervical cytologic smears has been an area of much controversy. This study compiled a list of criteria useful in identifying the subset of cases that would be categorized as atypical squamous cells of undetermined significance- rule out high-grade squamous intraepithelial lesion (ASC-H) in the new Bethesda System terminology, which eventuate in a diagnosis of cervical intraepithelial neoplasia (CIN). The cytopathology files at Johns Hopkins Hospital were searched for ASC-H cases from the 3-yr period 1996-1998, which had definitive clinicopathologic follow-up (colposcopy and cervical biopsies). The smears were reviewed, cytomorphologic features studied, and clinical correlations performed. ASC-H was diagnosed in 257 of 45,428 gynecologic smears (0.6%), 72 having had clinicopathologic follow-up. Of these 72 cases, 35 (49%) on follow-up had a negative/reactive diagnosis (NR), whereas 37 (51%) turned out to be CIN [CIN-I-18 (49%) and CIN II and III-19 (51%)]. The significant cytomorphologic differences in the ASC-H category with a CIN follow-up (compared with an NR follow-up) were fewer atypical cells, more often discohesive or seen singly, more monomorphic, a higher nuclear-to-cytoplasmic (N/C) ratio, greater nuclear hyperchromasia, more coarse, unevenly dispersed chromatin, more prominent nuclear membrane irregularities, lack of nucleoli, chromocenters or nuclear grooves, and lack of an inflammatory background. Careful attention to subtle cytomorphologic characteristics may be helpful for a more definitive subdivision of ASC-H terminology into a NR and a CIN diagnosis.     

HPV检测在“不典型鳞状细胞-不除外宫颈高度上皮内病变”中的意义

目的探讨高危型人乳头状瘤病毒(HR-HPV)检测对细胞病理学诊断为不典型鳞状细胞-不除外宫颈高度上皮内病变的(ASC-H)患者的临床处理价值。方法 2004年6月～2007年4月于中日友好医院妇产科门诊进行宫颈细胞学检查的患者17 125例,选择其中细胞学诊断结果为不典型鳞状细胞的患者,应用第二代杂交捕获方法检测HR-HPV,观察HR-HPV检测对细胞学诊断结果为ASC-H进行分流的意义。结果 HR-HPV阳性的ASC-H患者中宫颈高度病变的检出率(48.1%)显著高于ASC-US(25.2%),(P<0.01)。13例HR-HPV阴性的ASC-H患者中1例宫颈活组织检查结果为CIN2(5.9%),与ASC-US(5.7%)相比无差异。在ASC-US和ASC-H患者中,HR-HPV检测对于宫颈高度病变的敏感性分别为82.8%、96.2%,阴性预告值分别为94.3%,92.3%。结论对于HR-HPV阴性的ASC-H患者可以考虑定期随诊细胞学和高危型HPV,减少阴道镜检查,HR-HPV检测可能对于ASC-H患者同样具有分流作用。     

Atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion: the practice experience of a hospital-based reference laboratory with this new Bethesda system diagnostic category

The 2001 Bethesda System diagnostic category of atypical squamous cells cannot exclude a high grade squamous intraepithelial lesion (ASC-H) was developed and implemented after many studies that proved its clinical relevance. In this study, we describe the practice experience of a hospital-based reference laboratory with this new diagnostic category. The anatomic pathology computer database was searched, and 414 Papanicolaou (Pap) smears signed out as ASC-H were discovered among 60,390 Pap smear accessions over a 17-month period of time. One hundred four cases had corresponding tissue specimens. Slides from all Pap smears and tissue specimens were reviewed, and five Pap smears were reclassified, leaving 99 study cases. In our laboratory, 88.9% of the study cases had either low or high grade dysplasia diagnosed on subsequent tissue specimens. The positive predictive value of ASC-H for histologically proven high-grade squamous intraepithelial lesions (HSIL's) was 40.4%. Of those having human papillomavirus (HPV) hybrid capture II testing, high-risk HPV types were detected in 73.9% of cases. The majority of study cases had less than 25 atypical cells. In two hysterectomy cases and three loop electrosurgical excession procedure (LEEP) conization cases, high-grade dysplasia was present as a single microscopic focus, suggesting that the paucity of atypical cells in ASC-H Pap smears may be secondary to small lesion sampling. Thirteen study patients were postmenopausal and 30.8% had low-grade dysplasia, and of these, 46.2% had high-grade dysplasia on subsequent tissue specimens. In conclusion, our practice experience with ASC-H is similar to that reported in the literature before the 2001 Bethesda System.     

Screening properties of human papillomavirus testing for predicting cervical intraepithelial neoplasia in atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesion smears: a prospective study

The aim of the present study was to determine the usefulness of human papillomavirus (HPV) testing for predicting cervical intraepithelial neoplasia (CIN) 1 and 2 to 3 on cervical biopsies in women who had atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesion (LSIL) on Papanicolaou tests. In this prospective cohort, 167 women with abnormal cytologic examination (ASCUS and LSIL) were evaluated by colposcopy-directed biopsy and endocervical curettage. Colposcopy was performed on all study participants to obtain cervical tissue for histologic examination for detection of underlying CIN in patients with an initial cytologic test result of ASCUS and LSIL. A sample for HPV DNA detection by polymerase chain reaction was obtained. The HPV type 16 was positive in 35.4% of the 167 women with abnormal cytologic examination result in our gynecologic outpatient's clinic. Histologic diagnosis of CIN 1 was found in 45 of 135 women with ASCUS and in 17 of 32 women with LSIL. According to the cytologic findings, the frequency of CIN grade 2 or 3 in patients classified as ASCUS and LSIL was 12.5% (17/135) and 18.7% (6/32), respectively. Of the ASCUS smears, 9.6% were positive for HPV type 16. The sensitivity of the HPV type 16 using polymerase chain reaction technique threshold in detecting CIN 1 and CIN 2 to 3 was 57% and 46% in ASCUS-LSIL cytologic examination, respectively. The positive predictive value of HPV type 16 ranged from 60% in patients with CIN 1 and 42% in CIN 2 to 3 in ASCUS-LSIL. By contrast, negative predictive value was 58% in patients with CIN 1 and 80% in CIN 2 to 3. The low positive predictive value of HPV testing with ASCUS smears suggests that HPV positivity could be not used for predicting the presence of CIN 2 to 3.     

Negative loop electrosurgical excision procedure (LEEP) following cervical biopsy diagnosis of high grade squamous intraepithelial lesion

Context: Loop Electrosurgical Excision Procedure (LEEP) is commonly performed after cervical biopsy diagnosis of high grade squamous intraepithelial lesion (HSIL/CIN2 or CIN 3). Histological and immunohistochemical assessments are made to differentiate reactive and metaplastic changes from dysplastic changes. A Human Papillomavirus (HPV) test is used for prognostic assessment after conization. Objective: We retrospectively reviewed cases where the cervical biopsy showed HSIL but the LEEP specimen was negative for high grade dysplasia. Our aim was to determine the cause of miscorrelation. Data: IRB approval was obtained and a search was made of all LEEP specimens received during 2018. We reviewed 25 of 137 LEEP specimens that did not correlate with the diagnosis of HSIL rendered on the cervical biopsy. These were from women between 25 to 54 years. All cases had positive high-risk HPV with 80% being non16/18 subtype. On review, 8/25 had HSIL with the remainder of cases falling short of HSIL diagnosis. Follow up cytology with HPV test after the LEEP procedure was negative in all but one case of LSIL with persistent non-16/18 HPV. Conclusion: The study highlights the diagnostic difficulties of distinguishing HSIL from immature squamous metaplasia. The practical implication is that in cases with non-16/18 high risk HPV which have thin epithelium and fall short of definite morphologic criteria of HSIL, presence of immature squamous metaplasia should be carefully evaluated. The specific role of CK7 and CK17 which highlight squamocolumnar junctional cells and metaplastic cells, respectively, needs to be explored in these cases.     

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 andespecially high nuclear: cytoplasmic ratio and irregular chromatin were the most useful features in predicting high‐grade disease. Diagn. Cytopathol. 2013. © 2012 Wiley Periodicals, Inc.     

Cervical glandular atypia associated with squamous intraepithelial neoplasia: a premalignant lesion?

Recent studies have described premalignant changes in the endocervical epithelium, but morphological criteria for the diagnosis of cervical glandular atypia of lesser severity than adenocarcinoma in situ have not been established. Adenocarcinoma in situ is often associated with cervical intraepithelial neoplasia (CIN). The endocervical mucosa in 105 cases of CIN grade III was evaluated and compared with that of 100 controls. Sixteen cases of cervical glandular atypia and one case of adenocarcinoma in situ were identified, and it was possible to discriminate between these and a range of benign glandular lesions. Interestingly, the control series included two patients with cervical glandular atypia, one of whom on review had had a cone biopsy for CIN. The progression of cervical glandular atypia through adenocarcinoma in situ to invasive adenocarcinoma is known, but the natural history of cervical glandular atypia is as yet uncertain.     

薄层液基细胞学制片联合阴道镜检查对宫颈病变的诊断价值

目的评价薄层液基细胞学制片联合阴道镜检查对宫颈病变的诊断价值。方法对2006年1月～2008年12月在哈尔滨医科大学附属第四医院妇科门诊检查的1220例患者行宫颈薄层液基细胞学制片(TCT)检查,对其中186例细胞学提示阳性或临床高度可疑的患者行阴道镜下活组织病理检查,以病理诊断为金标准,对结果进行分析。结果宫颈薄层液基细胞学制片检查1220例中,异常涂片157例(12.59%),临床高度可疑的患者45例行阴道镜检查下活检。病理结果显示:CINⅠ39例,CINⅡ9例,CINⅢ3例,子宫颈鳞癌3例。TCT检查诊断宫颈病变符合率为84.0%,阴道镜检查对宫颈病变的诊断符合率为88.0%,两者比较差异具有显著性(P0.05),二者联合病变检出率为98.0%。结论采用薄层液基细胞学制片检查配合阴道镜下病理检查可明显提高对宫颈病变诊断的准确率,能满足早期发现癌前病变的需要。     

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.     

Loss of cytokeratin 14 expression is related to human papillomavirus type and lesion grade in squamous intraepithelial lesions of the cervix

In a recent study of low-grade cervical squamous intraepithelial lesions (SILs), we reported that infection with both low- and high-risk human papillomaviruses (HPVs) upregulated cyclin A, B, E, and Ki67 expression in basal and suprabasal cells. In view of the intricate link between cell cycle exit, proliferation, and differentiation, we examined the morphologic distribution of cytokeratins 13 and 14 and involucrin expression in 49 low-grade SILs infected with HPV types 6, 11, 16, 18, 31, 33, 39, 42, 43, 44, 45, 51, 52, 56, 58, and 66; 2 lesions contained both low- and high-risk HPVs. The findings were compared with 30 high-grade SILs infected with HPV types 16, 31, 33, 51, 58, 66, and 67; 3 of these were infected with 2 different HPVs. In low-grade lesions, the differentiation markers were expressed normally, showing that differentiation proceeds despite upregulation of cell cycle--associated proteins. Loss of involucrin (3 of 33) and cytokeratin 13 (8 of 33) expression occurred only in the high-grade lesions and was therefore related to lesion grade. Loss of cytokeratin 14 expression was also significantly more frequent in high-grade than in low-grade lesions (19 of 33 v 12 of 51; P < .01). In addition, cytokeratin 14 expression was significantly less frequent in the intermediate and superficial layers of low-grade SILs infected with high-risk HPVs than in those infected with low-risk HPVs (3 of 27 v 14 of 24; P < .001). These findings are consistent with in vitro data and suggest that abnormalities of both cell cycle control and squamous differentiation are important in HPV-associated neoplastic transformation.