Women ≥30 years of age with low grade squamous intraepithelial lesion (LSIL) have low positivity rates when cotested for high‐risk human papillomavirus: Should we reconsider HPV triage for LSIL in older women?

High‐risk human papillomavirus (HR‐HPV) testing for colposcopy triage of low grade squamous intraepithelial lesion (LSIL) is not recommended because of high positive rates in young women. It remains unclear whether HR‐HPV testing may be useful for triage of older women. We compiled HR‐HPV data for women aged ≥30 years with LSIL for the period March 1, 2006 to February 28, 2008. Follow‐up cervical biopsy information was collected for the period March 1, 2006 to August 15, 2008. We used the Hybrid Capture II test performed on residual material from liquid‐based Pap tests. Of 735 women, 254 had HR‐HPV testing, and of these 144 had positive HR‐HPV results. Among women with positive HR‐HPV results 79 underwent biopsy (54.9%) and 11 had cervical intraepithelial neoplasia (CIN) 2 or 3 (13.9% of women with biopsy follow‐up). A total of 481 women did not undergo HR‐HPV testing, of whom 192 underwent biopsy (39.9%) and 11 had CIN 2 or 3 (5.7% of biopsied women [P = 0.04]). Among women who tested negative for HR‐HPV and had follow‐up biopsies, only one had a high grade lesion found (CIN 2). The overall HR‐HPV positive rate in tested women ≥30 years old with LSIL was 56.7% if women who had reflex HR‐HPV testing for ASC‐US are included. The HR‐HPV positive rate in residual material from Pap tests interpreted as LSIL was 63.8%. Among women ≥30 years of age with LSIL, CIN 2‐3 is significantly more likely in HR‐HPV positive women. Relatively few older women with LSIL test positive for HR‐HPV. Colposcopy triage using HR‐HPV may be justified in this population. Diagn. Cytopathol. 2010. © 2009 Wiley‐Liss, Inc.     

Evaluation of p16 immunostaining to predict high‐grade cervical intraepithelial neoplasia in women with Pap results of atypical squamous cells of undetermined significance

p16 immunostaining has been examined to detect high‐grade cervical intraepithelial neoplasia grade (CIN2+) in Pap cytology specimens. However, the utility of p16 in predicting CIN2+ in Pap specimens with atypical squamous cells of undetermined significance (ASC‐US) or atypical squamous cells, cannot exclude high‐grade squamous intraepithelial neoplasm (ASC‐H), is controversial. In this study, we evaluated the utility of p16 immunostaining for predicting CIN2+ in 78 Pap specimens with ASC‐US/ASC‐H and compared the results in high‐risk HPV DNA and the follow‐up biopsies. p16 immunostaining was positive in 47% (37/78) of the Pap specimens. Of the 13 Pap specimens with follow‐up biopsy results of CIN2+, 7 (54%) were positive for p16. p16 positivity in the Pap specimens was not significantly associated with a CIN2+ biopsy result (P = 0.76). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of p16 immunostaining for predicting CIN2+ were 54%, 52%, 19%, and 85%, respectively. High‐risk HPV DNA was detected in 40% (31/78) of the Pap specimens. The sensitivity, specificity, PPV, and NPV of HPV DNA for predicting CIN2+ were 100%, 72%, 42%, and 100%, respectively. High‐risk HPV genotypes were detected in six p16‐negative specimens with follow‐up biopsy results of CIN2+. Our findings suggest that the utility of p16 immunostaining for predicting CIN2+ in Pap specimens with ASC‐US/ASC‐H is limited. Scant abnormal cells in Pap specimens with ASC‐US/ASC‐H may have contributed to the low p16 sensitivity. Diagn. Cytopathol., 2011. © 2010 Wiley‐Liss, Inc.     

Utility of P16 expression and Ki‐67 proliferation index in ASCUS and ASC‐H pap tests

Current cervical screening uses a combination of cytology and high‐risk human papillomavirus (HR‐HPV) analysis in cases of atypical squamous cells of undetermined significance (ASCUS) and atypical squamous cells cannot exclude high‐grade intraepithelial lesion (ASC‐H). These diagnoses are subject to interobserver variability and HR‐HPV analysis can be limited by sampling inadequacy. This study correlates immunoexpression of P16 and Ki‐67 in residual cervicovaginal material against cytology category and HR‐HPV status. Eighteen pap tests were selected: 8 ASCUS, 4 ASC‐H, and 6 controls (2 LSIL and 4 HSIL). Digene Hybrid Capture II test was used to detect HR‐HPV. The cytospins were stained for P16/Ki‐67. Pap tests, P16, Ki‐67, HR‐HPV result and available biopsies were correlated. P16 expression correlated with HR‐HPV status in 15/17 cases. Discordant cases (1 ASCUS and 1 ASC‐H) were +P16/–HR‐HPV. Ki‐67 correlated with HR‐HPV in 8/15 cases. Discordant cases were +HR‐HPV/– Ki‐67 (HSIL, LSIL, and ASC‐H one each), and –HR‐HPV/+Ki‐67 (3 ASCUS, 1 LSIL, 1 ASC‐H). Two cases were + P16/+ Ki‐67/– HR‐HPV. None were ‐ P16/– Ki‐67/+ HR‐HPV. Histologic follow‐up in 13 cases varied from benign to CIN III. Two cases of +P16/ – Ki‐67/– HR‐HPV had benign cervical biopcies. Although a small sample size, our findings show a utility for adjunct P16/ Ki‐67 in addition to HR‐HPV testing in cases of squamous atypia when HR‐HPVs are non‐detected due to low DNA copies, or missed lesions in cervical biopsies. Diagn. Cytopathol. 2014;42:576–581. © 2013 Wiley Periodicals, Inc.     

Triage of cervical cytological diagnoses of atypical squamous cells by DNA methylation of paired boxed gene 1 (PAX1)

Detection of cervical high‐grade squamous intraepithelial lesions (HSIL) in patients with equivocal cytological abnormalities, such as atypical squamous cells (ASC) of undetermined significance (ASCUS) or inability to exclude high‐grade squamous intraepithelial lesions (ASC‐H) is still a challenge. This study tested the efficacy of PAX1 methylation analysis in the triage of cervical ASCUS and ASC‐H and compared its performance with Hybrid Capture 2 (HC2) HPV test. A hospital‐based case–control study was conducted. Cervical scrapings from patients with ASCUS or ASC‐H were used for the quantitative methylation analysis of PAX1 methylation by MethyLight and HPV testing by HC2. Patients with ASC‐H or ASCUS with repeated abnormal smears underwent colposcopic biopsy and subsequent therapies. Diagnoses were made by histopathology at a follow‐up of 2 years. The efficacies of detecting high‐grade lesions were compared. Fifty‐eight cervical scrapings with cytological diagnosis of ASCUS (n = 41) and ASC‐H (n = 17) were analyzed. One of the 41 (2.4%) ASCUS patients and seven of 17 (41.2%) ASC‐H patients were confirmed to have HSIL. After dichotomy of the PMR, PAX1 methylation rates were significantly higher in ASC developing HSIL compared with those developing reactive atypia (87.5% vs. 12.5%, P < 0.001). Testing PAX1 methylation in cervical swabs of patients with ASC confers better sensitivity (87.5% vs. 62.5%) and specificity (98.0% vs. 86.0%) than HC2 HPV testing. We show for the first time that PAX1 hypermethylation analysis may be a better choice than HC2 in the triage of ASCUS and ASC‐H. Diagn. Cytopathol. 2013. © 2011 Wiley Periodicals, Inc.     

Reflex high-risk human papilloma virus DNA test is useful in the triage of women with atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion

This study is aimed to investigate the role of reflex high-risk human papilloma virus (HPV) DNA testing as an alternative triage method to colposcopy for women with atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H) on Papanicolaou (Pap) tests. Reflex HPV DNA testing using Hybrid Capture II method was carried out on 88 women with ASC-H diagnosed by Thin Prep Pap test. Correlation with follow-up biopsies was available on 42 of these patients. The reflex HPV DNA test showed an overall positive rate of 67% and negative rate of 33% in 88 patients with ASC-H. Using age 30 as the cut off point, the positive rate had increased to 83.3% (35/42) in patients 30 yr or younger, while the positive rate for patients older than 30 yr had decreased to 52.2% (24/46). Follow-up colposcopic biopsy results were available in 35 of 59 HPV-positive women, which revealed 15 (43%) high-grade squamous intraepithelial lesions (HSIL), 12 low-grade squamous intraepithelial lesions (LSIL), and 8 negative for dysplasia. In 7 HPV-negative patients, the follow-up biopsies showed no evidence of HSIL or LSIL. Correlation between clinical risk factors and the HPV results demonstrated no significant differences in HPV positivity between the high-risk and low-risk patients. The high sensitivity (100%) and negative predictive rate (100%) in detecting HSIL in our study provide strong evidence that, instead of automatic referral to colposcopy, reflex HPV DNA testing may be used as an alternative triage method for women diagnosed with ASC-H on Thin Prep Pap test, especially for women older than 30 yr of age.     

Qualification of ASCUS. A comparison of equivocal LSIL and equivocal HSIL cervical cytology in the ASCUS LSIL Triage Study

Cytologic detection of high-grade squamous intraepithelial lesions (HSILs) is critical to cervical cancer prevention. Therefore, identifying "equivocal HSIL" (ASCUS [atypical squamous cells of undetermined significance]-H) may be useful. Accordingly, we compared findings associated with "equivocal low-grade SIL" (ASCUS-L), ASCUS-H, and HSIL using data from the ASCUS LSIL (low-grade squamous intraepithelial lesion) Triage Study. The frequency of oncogenic human papillomavirus (HPV) DNA detection and underlying lesions cervical intraepithelial neoplasia (CIN) 2 or worse or CIN 3 or worse in women with ASCUS-H was intermediate between that of ASCUS-L and HSIL. Oncogenic HPV DNA was associated with 85.6% of ASCUS-H ThinPreps and 69.8% of ASCUS-H smears. Histopathologic lesions CIN 2 or worse were associated with 40.5% of ASCUS-H ThinPreps and 27.2% of ASCUS-H smears (mostly CIN 3). Nevertheless, numerically more lesions CIN 2 or worse were preceded by ASCUS-L than by ASCUS-H because ASCUS-L was more common. ASCUS-H is an uncommon interpretation that derives clinical usefulness from its high positive predictive value for lesions CIN 2 or worse.     

Management of atypical squamous cells of undetermined significance or low‐grade squamous intraepithelial lesions of the uterine cervix with human papilloma virus infection among young women aged less than 25 years

Current ASCCP guidelines recommend repeat cytology 12 months after HPV‐positive results in women aged 21–24 years with either atypical squamous cells of undetermined significance (ASCUS) or a low‐grade squamous intraepithelial lesion (LSIL). The purpose of this study was to validate an algorithm in such women with ASCUS or LSIL. A multicenter cross‐sectional study was carried out at three academic hospitals involving 40,847 Korean women who underwent cervical cancer screening with cytology and HPV testing with or without subsequent colposcopic biopsies between January 2007 and December 2013. Among a total of 3,193 women with available histopathology data, 762 women with ASCUS and 758 with LSIL were HPV‐positive. Among HPV‐positive women with ASCUS, 38.5% of women aged 21–24 years had ≥CIN2, compared to 20.8% of women aged 30–65 years and 21.1% of the total women. Among HPV‐positive women with LSIL, 25.8% aged 21–24 years had ≥CIN2, compared to 21.2% of women aged 30–65 years and 21.9% of the total women. In HPV‐positive women with ASCUS/LSIL aged less than 25 years, the prevalence of ≥CIN2 lesions was 34.5%, which was significantly higher than that (21.0%) in women aged ≥25 years. The risk of ≥CIN2 lesions in HPV‐positive Korean women aged 21–24 years with ASCUS or LSIL was not lower than that in older women. Colposcopic examination should be considered for management of HPV‐positive young women with ASCUS or LSIL. Diagn. Cytopathol. 2016;44:959–963. © 2016 Wiley Periodicals, Inc.     

Prevalence and typing of HPV DNA by hybrid capture II in women with ASCUS, ASC-H, LSIL, and AGC on ThinPrep Pap tests

Testing for human papillomavirus (HPV) DNA is now a viable option for the management of women with atypical squamous cells of undetermined significance (ASCUS). The utility of reflexive HPV DNA testing for women with a cytologic diagnosis of atypical glandular cells-not otherwise specified (AGC-NOS), ASCUS subtypes, and low-grade squamous intraepithelial lesion (LSIL) has not been well established. In the present investigation, reflex Hybrid Capture II HPV DNA testing results were evaluated for HPV prevalence and type in 371 women with abnormal cytologic diagnoses of ASCUS-not otherwise specified (ASCUS-NOS), ASCUS-suspicious for low-grade squamous intraepithelial lesion (ASCUS-L), atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion (ASC-H), AGC-NOS, and LSIL on ThinPrep Pap tests. Positive high-risk HPV DNA was identified in 53.6% of the study samples, including ASCUS-NOS 40.2% ASCUS-L 71.4%, ASC-H 37.5%, LSIL 88.6%, and AGC-NOS 0%. We conclude that reflex HPV DNA testing appears to not be useful for colposcopy triage for cytologic diagnoses of LSIL or AGC-NOS.     

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

In this study we evaluated CDP: EWC, a large public health screening program for low‐income women to determine whether the ASC‐H term, introduced in the 2001 revision to the Bethesda System, has facilitated the detection of the most serious precancerous cervical lesions such as CIN‐II–III/CIS, including accuracy of detection and minimizing diagnostic delays. Pap test and biopsy data from the period 2003–2006 were compared with those from 1995–1999, and included analysis of a subset of rarely and never‐screened for each study period. More ASC‐H Pap tests were followed by CIN‐II+ biopsies (20%) than ASCUS Pap tests (5%). Thirteen percent of ASC‐H showed CIN‐III/CIS on follow‐up biopsy. Following the introduction of ASC‐H, negative and LSIL Pap tests followed by CIN‐III/CIS biopsies decreased from 5.6% to 0.37% and 9.2% to 4.4%, respectively. Fewer CIN‐III/CIS cases were preceded by Pap tests with negative and ASCUS results in 2003–2005 as compared with 1995–1999. The number of days from screening to diagnosis for women aged 25–39 years with ASC‐H Pap test results (58 days) was less than for ASCUS results (78 days) for the current study period. In this high‐risk multi‐ethnic population, ASC‐H more effectively communicates equivocal findings likely to represent HSIL leading to more rapid follow‐up. The incidence of CIN‐II or CIN‐III/CIS following ASC‐H Pap tests is lower than generally appreciated for this population, including for rarely or never‐screened high‐risk women. Fewer CIN‐III/CIS lesions were detected following negative and ASCUS Pap results. Compliance with follow‐up is less than ideal for this population. Diagn. Cytopathol. 2009. © 2008 Wiley‐Liss, Inc.     

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.     

Negative computer‐imaged ThinPrep Pap test and positive hybrid capture2 HPV co‐testing results: A quality assurance review

Women ≥30 years of age with negative (?) Pap tests and positive (+) HPV co‐test results have a higher prevalence and cumulative risk of developing high‐grade cervical intraepithelial neoplasia (CIN 2+). Thus, the current management in these women is to repeat co‐test in 12 months or immediate reflex genotyping for HPV16 or HPV 16/18. If genotyping is not an option, timely quality assurance (QA) rescreen of such Pap tests may be a valuable alternative. All ThinPrep Pap tests (TPPT) interpreted as negative for intra epithelial lesion (NILM) or NILM with reactive cellular changes (NILM/RCC) and a (+) high‐risk HPV [Hybrid Capture 2 (HC2), Qiagen, Hilden, Germany] co‐test result over a 45‐month period (10/2009‐06/2013) underwent monthly QA review. The TPPT were screened by the TP Imaging System [TIS, Hologic Inc., Bedford, MA]. Twenty five thousand six hundred and seventy five (18%) NILM and NILM/RCC TPPT of a total of 141,548 TPPT underwent HPV co‐test. HPV test was (+) in 2,300 (8.9%) TPPT cases. HPV (+) cases by age group were <30 years, 486 (21%), and ≥30 years, 1,814 (79%). Upon QA review, 10 cases (0.4%) were reclassified, with significant findings in three cases in ≥30 years. Two cases showed high‐grade squamous intraepithelial lesion (HSIL) on repeat Pap, and one case showed endocervical adenocarcinoma in situ (AIS) on biopsy. Timely QA review of HPV (+) Pap (?) co‐tests is a valuable monitor. Ninety percentage of reclassified cases were in ≥30 age group and 70% were originally signed out by using TIS 22 Field of View (FOV) only. Three reclassified cases had significant findings on follow up (F/U). Diagn. Cytopathol. 2015;43:763–769. © 2015 Wiley Periodicals, Inc.     

Limiting factors for cytopathological diagnosis of high-grade squamous intraepithelial lesions: a cytohistological correlation between findings in cervical smears and loop electrical excision procedure.

The present study sought possible factors leading to the cytological diagnosis of atypical squamous cells of uncertain significance (ASCUS) in cases of high-grade squamous intraepithelial lesions (HSIL). Based on retrospective histopathological analysis of loop electrical excision procedure (LEEP) products that diagnosed HSIL, two study groups were randomly selected. The first was consisted of cases with two consecutive Papanicolaou (Pap) smears with the diagnosis of ASCUS. The second (control) group was represented by cases diagnosed as HSIL by cytology. From the Pap smears diagnosed as ASCUS, the sampling limitations was different from control group (P < 0.05). The median size of the largest lesion in each case with ASCUS was 2.66 mm (+/- 1.71 mm). In the control group, the median size of the largest lesion was 5.15 mm (+/-2.58 mm) (P < 0.05). The size of the lesion and sample limitations led patients with cervical intraepithelial neoplasms to be diagnosed as ASCUS for two consecutive times, after a 6-mo period.     

The impact of LSIL‐H terminology on patient follow‐up patterns

The Papanicolaou (Pap) test category of “low grade squamous intraepithelial lesion, cannot exclude high grade squamous intraepithelial lesion” (LSIL‐H) is not recognized by The Bethesda System but is commonly used. It is essentially an amalgamation of the official LSIL and ASC‐H categories. Since these two categories have similar follow‐up algorithms, the clinical utility of the combined LSIL‐H category is unclear. We have therefore studied follow‐up patterns for these three entities in our laboratory to determine the real‐world impact of each in our patient population. We searched our pathology database over an 18‐month period to find Pap tests (predominantly ThinPrep) interpreted as LSIL‐H (137), LSIL (2,189), and ASC‐H (101). Like other studies, we found that the discovery rate of high grade dysplasia in biopsies after LSIL‐H (31.9%) was similar to ASC‐H (35.3%) and was higher than LSIL (7.6%; P < 0.0001). In women with no previous history of dysplasia, the frequency of biopsy follow‐up after the initial Pap test was significantly higher for LSIL‐H (68.3%) than for LSIL (49.6%; P = 0.0038) and similar to ASC‐H (62.3%). We also found that women with an initial negative biopsy or a biopsy positive for low grade dysplasia were more likely to undergo an additional biopsy if the initial Pap test was LSIL‐H (36.2%) than if it was LSIL (18.2%; P = 0.0023). ASC‐H (26.9%) had an intermediate rate. In our patient population, the use of the terminology LSIL‐H is associated with follow‐up biopsy patterns much more similar to ASC‐H than to LSIL. Diagn. Cytopathol. 2013;41:960–964. © 2013 Wiley Periodicals, Inc.     

Endocervical component: Is it a determinant of specimen adequacy?

There is controversy in the literature concerning the presence or absence of an endocervical component as a determinant of the adequacy of cervical cellular samples. The purpose of this retrospective 2-yr study (January 1, 1999-December 31, 2000) was to evaluate the diagnostic accuracy of ThinPrep Pap Tests with the presence or absence of an endocervical component from 151 women with subsequent tissue-verified cervical intraepithelial neoplasia (CIN) II/III. Of the 138 Pap Tests containing an endocervical component, 100 (73%) showed exact cyto/histologic correlation and 38 (27%) were discordant. Of the 13 Pap Tests lacking an endocervical component, 10 (77%) showed exact correlation and 3 (23%) were discordant. Statistical analysis showed no significant difference in the detection of a high-grade squamous intraepithelial lesion (HSIL) in those ThinPreps that contained an endocervical component from those that did not (P > 0.5). Further analysis of the 41 discordant ThinPrep Pap Tests showed no significant difference between negative Pap Tests and discordant, yet abnormal Pap Tests (atypical squamous cells of undetermined significance, or low-grade squamous intraepithelial lesions) and the presence or absence of an endocervical component (P = 0.25). The results of this study seem to indicate that the issue of the lack of an endocervical component as a determinant of cervical specimen adequacy should be revisited.     

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

Despite the two‐tiered classification of dysplasia in The Bethesda System (TBS), rare cases fall into the category squamous intraepithelial lesion (SIL) of indeterminate grade. These Pap tests are often interpreted as “LSIL/ASC‐H” or “LSIL” with a comment indicating the presence of cells with features approaching HSIL. Patients with LSIL/ASC‐H have a significant risk of CIN 2 or worse (29–61.5%) on follow‐up cervical biopsies, similar to the risk of CIN 2 or worse in patients with ASC‐H Pap tests (24–68%). The purpose of this study was to compare patients with ASC‐H and LSIL/ASC‐H Pap tests. Women with LSIL/ASC‐H had a slightly lower incidence of CIN 2 or worse (PPV = 35.6%, 95% CI: 29.8–41.4%) on follow‐up cervical biopsy than the control ASC‐H group (PPV = 40.2%, 95% CI: 31.9–56.3%); this difference was not statistically significant. The difference in the distribution of the biopsy results between the two groups was statistically significant (P < 0.001). The current guidelines for the management of cervical cytologic abnormalities from the American Society for Colposcopy and Cervical Pathology (ASCCP) advocate similar treatment algorithms for both LSIL and ASC‐H. The main difference is the option of cytologic follow‐up or HPV testing for certain “special populations,” as an alternative to colposcopy, for LSIL Pap test results. Based on our results, we recommend (1)LSIL/ASC‐H to be added to TBS classification and (2) Pap test cases of LSIL/ASC‐H may need to be clinically followed in a manner similar to ASC‐H, i.e., colposcopy for all patients. Diagn. Cytopathol. 2010. © 2009 Wiley‐Liss, Inc.     

Is the human papillomavirus test in combination with the Papanicolaou test useful for management of patients with diagnoses of atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesions?

OBJECTIVE: To determine whether human papillomavirus (HPV) testing is useful in the evaluation of patients diagnosed with atypical squamous cells of undetermined significance (ASCUS)/low-grade squamous intraepithelial lesion (LSIL) and whether the HPV test is appropriate as an alternative screening method. DESIGN: The results of Papanicolaou (Pap) tests and subsequent hybrid capture tube (HCT) II tests for high-risk-type HPV were analyzed for 457 patients. Among these tests, 208 histologic diagnoses were made and correlated with the results of Pap and HPV tests. The sensitivity and specificity of the Pap test, HPV test, and the combined method of Pap and HPV tests to detect cervical intraepithelial neoplasia (CIN) 2/3 and all CIN were also measured. RESULTS: Sixty (63.8%) of 94 women with LSIL and 31 (26.3%) of 118 women with ASCUS tested positive for high-risk HPV. The sensitivity values for Pap tests in detecting all cases of CIN and CIN 2/3 were 91.4% and 92.9%, respectively. The sensitivity values of HCT II tests using the high-risk probe for detecting all cases of CIN and CIN 2/3 were 62.6% and 88.1%, respectively. Biopsies confirmed that 10 (22.7%) of 44 LSIL patients with high-risk HPV had CIN 2/3, but only 1 (4.5%) of 22 LSIL patients without high-risk HPV had CIN 2/3. CONCLUSION: Testing for high-risk HPV with the HCT II test is useful in the detection of CIN 2/3 in LSIL groups and in the selection of patients for colposcopy in ASCUS groups, but it is not suitable for cervical cancer screening tests.     

Viral load and physical status of human papillomavirus (HPV) 18 in cervical samples from female sex workers infected with HPV 18 in Burkina Faso

Viral DNA load and physical status might be predictive of either high‐grade cervical lesions or disease progression among women infected by human papillomavirus (HPV) 16, but these virological markers have rarely been studied in HPV 18 infections. The relationships between HPV 18 DNA load, viral genome physical status and cervical squamous intraepithelial lesions were analyzed among female sex workers infected with HPV18 in Burkina Faso. HPV 18 E2 and E6 genes were quantitated by real‐time PCR. Among 21 women infected with HPV 18, 67% of whom were HIV‐1‐seropositive, 11 (52.4%) had a normal cytology, 8 (38.1%) had low‐grade squamous intraepithelial lesions, and 2 (9.5%) had high‐grade squamous intraepithelial lesions. Total viral load and integrated viral load were higher in women with squamous intraepithelial lesions than in women with normal cytology (P = 0.01 for both parameters). Total viral load and integrated viral load were higher in HIV‐1‐seropositive women than in those who were not infected with HIV (P = 0.01, and P, 0.01, respectively). Total viral load or integrated viral load >1,000 copies/ng of DNA were more frequent in women with squamous intraepithelial lesions than in women with normal cytology (7/10 vs. 1/11; P = 0.007) and in HIV‐1‐seropositive women (8/14 vs. 0/7 in HIV‐uninfected women; P = 0.02). Both HPV 18 DNA and integrated DNA loads might represent markers of cervical lesions. Prospective evaluations are needed to establish the value of these parameters to predict high‐grade lesion or lesion progression. J. Med. Virol. 81:1786–1791, 2009. © 2009 Wiley‐Liss, Inc.     

Atypical glandular cells of undetermined significance (AGUS): cytopathologic features, histopathologic results, and human papillomavirus DNA detection.

We intensively reviewed 137 smears initially classified as atypical glandular cells of undetermined significance (AGUS) to refine cytological criteria for evaluating these cases, evaluate histological outcomes, and assess the value of human papillomavirus (HPV) DNA testing in management. Consenting, nonpregnant study participants were identified from a cohort of 46,009 women receiving routine Pap smear screening in a managed care setting. Colposcopy was performed on all women, and at least one histological sample was obtained from each. Review diagnoses were assigned to smears and biopsy specimens by two separate panels of pathologists. DNA testing for cancer-associated HPV types was performed on rinses of cytological samplers after a smear and thin-layer slide had been made. On review, 47 (34%) smears were reclassified as negative, 44 (32%) as AGUS, 30 (22%) as atypical squamous cells of undetermined significance (ASCUS), and 16 (12%) as squamous intraepithelial lesions (SIL). The 19 smears interpreted as high-grade intraepithelial lesions on review included 13 high-grade SIL (HSIL), two HSIL with AGUS, favor neoplastic (endocervical adenocarcinoma in situ [AIS]), and four AGUS, favor neoplastic (AIS). Review histological diagnoses were negative in 105 (77%), squamous or glandular atypia in four (3%), low-grade SIL (LSIL) in nine (7%), HSIL in 12 (9%), AIS in five (4%, including two with concurrent HSIL), and endometrial carcinoma in one (1%). HPV testing identified 11 (92%) of 12 women with histologically confirmed HSIL and all five with AIS (100%). A high-grade intraepithelial lesion or carcinoma is detected in approximately 14% of women with community-based diagnoses of AGUS who are referred for immediate evaluation. Use of refined cytological criteria and HPV DNA testing may permit improved management of women with AGUS.     

Point-Counterpoint: Cervical Cancer Screening Should Be Done by Primary Human Papillomavirus Testing with Genotyping and Reflex Cytology for Women over the Age of 25 Years

Screening for cervical cancer with cytology testing has been very effective in reducing cervical cancer in the United States. For decades, the approach was an annual Pap test. In 2000, the Hybrid Capture 2 human papillomavirus (HPV) test was approved by the U.S. Food and Drug Administration (FDA) for screening women who have atypical squamous cells of underdetermined significance (ASCUS) detected by Pap test to determine the need for colposcopy. In 2003, the FDA approved expanding the use of the test to include screening performed in conjunction with a Pap test for women over the age of 30 years, referred to as “cotesting.” Cotesting allows women to extend the testing interval to 3 years if both tests have negative results. In April of 2014, the FDA approved the use of an HPV test (the cobas HPV test) for primary cervical cancer screening for women over the age of 25 years, without the need for a concomitant Pap test. The approval recommended either colposcopy or a Pap test for patients with specific high-risk HPV types detected by the HPV test. This was based on the results of the ATHENA trial, which included more than 40,000 women. Reaction to this decision has been mixed. Supporters point to the fact that the primary-screening algorithm found more disease (cervical intraepithelial neoplasia 3 or worse [CIN3+]) and also found it earlier than did cytology or cotesting. Moreover, the positive predictive value and positive-likelihood ratio of the primary-screening algorithm were higher than those of cytology. Opponents of the decision prefer cotesting, as this approach detects more disease than the HPV test alone. In addition, the performance of this new algorithm has not been assessed in routine clinical use. Professional organizations will need to develop guidelines that incorporate this testing algorithm. In this Point-Counterpoint, Dr. Stoler explains why he favors the primary-screening algorithm, while Drs. Austin and Zhao explain why they prefer the cotesting approach to screening for cervical cancer.