Comparative sensitivities of ThinPrep and Papanicolaou smear for adenocarcinoma in situ (AIS) and combined AIS/high-grade squamous intraepithelial lesion (HSIL): comparison with HSIL

BACKGROUND: Despite the historic belief that cytologic screening offers little protection against cervical adenocarcinoma (CAC), there is emerging evidence that, by detecting the precursor lesion, adenocarcinoma in situ (AIS), cervical screening may reduce the incidence of CAC as it has for cervical squamous carcinoma. Because liquid-based cytology is fast replacing the conventional Papanicolaou smear (PS), it is important to establish that it is at least as effective in detecting AIS. METHODS: The authors calculated the sensitivities of PS and ThinPrep (TP) for 100 women with histologic AIS (from 160 PS slides and 60 TP slides), for 94 women with AIS+high-grade squamous intraepithelial lesion (HSIL) (from 151 PS slides and 50 TP slides), and for 558 women with HSIL (from 788 PS slides and 383 TP slides). All smears were taken up to 36 months before the histologic diagnosis. RESULTS: In no category was there a significant difference between PS sensitivity and TP sensitivity. The HSIL category had a significantly higher overall sensitivity than the other categories. However, when sensitivity was defined as cytologic detection of high-grade disease, there was no difference between any of the categories. For the detection of a high-grade glandular lesion, the presence of a concurrent histologic HSIL was associated with reduced sensitivity for the detection of AIS. CONCLUSIONS: The current results indicated that it may prove possible for cervical screening, with either PS or TP, to reduce the incidence of CAC.     

The role of deeper levels and ancillary studies (p16Ink4a and ProExC) in reducing the discordance rate of Papanicolaou findings of high‐grade squamous intraepithelial lesion and follow‐up cervical biopsies

BACKGROUND:

Discordant results of cervical biopsy histology after a cytologic diagnosis of high‐grade squamous intraepithelial lesion (HSIL) are often attributed to sampling variation. The purpose of the current study was to determine whether deeper levels and ancillary staining (p16^Ink4a and ProExC) reduce the discordant rate.

METHODS:

A total of 246 cases of HSIL were retrieved from the computerized database from 2005 and 2006. Of these cases, 151 were followed by cervical biopsy. There was cytologic‐histologic correlation in 87 cases, as defined by the presence of high‐grade (2 or 3) cervical intraepithelial neoplasia (HGCIN). For each discordant biopsy (n = 64), 2 deeper levels for hematoxylin and eosin (H&E) were taken at 30‐μ and 90‐μ depths, and 4 sections for p16^Ink4a and ProExC staining were taken at a 60‐μ depth. All cytologic and histologic material from these 64 cases was reviewed by 3 cytopathologists. In 2 cases, the original HSIL diagnoses were downgraded and the cases censored from the study.

RESULTS:

Fifty‐seven of the 62 discordant cases had sufficient tissue for deeper levels and ancillary staining. Two of 57 cases were reclassified to HGCIN. In both of these cases, reclassification was suggested by results of immunostains; however, the H&E sections were necessary for definitive interpretation of the immunostain results.

CONCLUSIONS:

In the current study, deeper levels and ancillary staining with p16^Ink4a and ProExC did not significantly reduce the discordance rate. Although there are many known causes of sampling variation, including factors related to colposcopic technique, regression of infection, and insufficient histologic sectioning, sampling variation remains a valid justification of noncorrelation in women with HSIL followed up by cervical biopsy alone. Cancer (Cancer Cytopathol) 2009. © 2009 American Cancer Society.     

Histopathologic follow-up and human papillomavirus DNA test results in 290 patients with high-grade squamous intraepithelial lesion Papanicolaou test results

BACKGROUND:

The study documents histopathologic outcomes and high‐risk (hr) human papillomavirus (HPV) test results in a large cohort of patients with high‐grade squamous intraepithelial lesion (HSIL) liquid‐based cytology (LBC) Pap test results.

METHODS:

A total of 352 patients with HSIL results (338 cervical and 14 vaginal) who had hrHPV testing and 290 patients with biopsy follow‐up were studied. hrHPV detection rates were compared at different ages, with or without an endocervical/transformation zone sample (EC/TZS), and for cervical and vaginal HSIL Pap smears. Histopathologic follow‐up findings were also compared. hrHPV‐negative HSIL slides were re‐evaluated in a blinded manner.

RESULTS:

A total of 325 of 338 (96.2%) cervical HSIL and 12 of 14 (87.5%) vaginal HSIL tested hrHPV‐positive. A total of 271 of 281 (96.4%) EC/TZS‐positive cervical HSIL and 54 of 57 (94.7%) EC/TZS‐negative cervical HSIL tested hrHPV‐positive. The percentage of hrHPV‐positive HSIL declined slightly with increasing age. 197 of 273 (72.3%) hrHPV‐positive cervical HSIL had histopathologic cervical intraepithelial neoplasia (CIN) 2/3+ follow‐up, including 8 squamous carcinomas, compared with 4 of 12 (33.3%) hrHPV‐negative HSIL with CIN2/3 (no carcinomas). 167 of 241 (69.2%) EC/TZS‐positive HSIL had CIN2/3+ follow‐up, compared with 34 of 44 (77.3%) EC/TZS‐negative HSIL. Equivocal HSIL morphology characterized some HPV‐negative HSIL without CIN2/3+ follow‐up.

CONCLUSIONS:

hrHPV was detected in LBC vials from 96.2% of 338 cervical HSIL and 85.7% of 14 vaginal HSIL. CIN2/3+ was significantly more likely with hrHPV‐positive cervical HSIL than with hrHPV‐negative cervical HSIL. Presence or absence of an EC/TZS did not significantly impact HSIL hrHPV or CIN2/3+ rates. Some hrHPV‐negative HSIL cases may represent HSIL cytologic mimics. Cancer (Cancer Cytopathol) 2011;. © 2011 American Cancer Society.     

Clinical significance of the diagnosis of low‐grade squamous intraepithelial lesion,cannot exclude high‐grade squamous intraepithelial lesion

BACKGROUND:

The diagnosis of low‐grade squamous intraepithelial lesion (LSIL), cannot exclude high‐grade squamous intraepithelial lesion (LSIL‐H) was not included in the 2001 Bethesda System. It is used in some institutions to diagnose cases that fulfill criteria for both the diagnosis of LSIL and atypical squamous cells, cannot exclude high‐grade squamous intraepithelial lesion (ASC‐H). In this study, the authors reviewed their experience with cases reported as LSIL‐H during a 4‐year interval.

METHODS:

Clinical information and histologic follow‐up data were retrieved for Papanicolaou (Pap) tests (PTs) that were diagnosed as LSIL‐H, LSIL, ASC‐H and high‐grade squamous intraepithelial lesion (HSIL) from January 1, 2004 to December 31, 2007.

RESULTS:

Of 235,645 PTs (97% SurePath) that were processed during the study period, the laboratory diagnosed 0.52% as ASC‐H, 2% as LSIL, 0.30% as LSIL‐H, and 0.39% as HSIL. Biopsy follow‐up was available for 47%, 49%, 56.7% and 74% of these cases, respectively. Cervical intraepithelial neoplasia 2 (CIN‐2) and CIN‐3 or more severe lesions (CIN‐3+) were identified on follow‐up cervical biopsy more often in women who had diagnoses of LSIL‐H and ASC‐H (33.14% and 26.33%, respectively) than in women who had a diagnosis of LSIL (16.11%).

CONCLUSIONS:

The similarity of histologic follow‐up results between LSIL‐H and ASC‐H suggested that the management of women who have a diagnosis of LSIL‐H should be similar to the management of women who have a diagnosis of ASC‐H. Cancer (Cancer Cytopathol) 2009. © 2009 American Cancer Society.     

Evaluation of quantity and staining pattern of human papillomavirus (HPV)‐infected epithelial cells in thin‐layer cervical specimens using optimized HPV‐CARD assay

BACKGROUND.

Testing for human papillomavirus (HPV) is used in the triage of women with a cervical cytology of atypical squamous cells of undetermined significance (ASCUS). A fluorescent in situ hybridization assay was developed for the detection of HPV using the catalyzed receptor deposition technique (HPV‐CARD). In this study, the utility of this assay was tested for the detection of HPV in liquid‐based cervical cytology specimens.

METHODS.

A total of 195 liquid‐based cytology specimens were analyzed using the HPV‐CARD assay. The results from the assay were compared with HPV polymerase chain reaction (PCR) and typing results. The number of HPV‐infected cells and the staining pattern was correlated with the cytology classification.

RESULTS.

A 91% concordance between HPV‐CARD and PCR was observed for the detection of high‐risk HPV viruses. A 78% concordance was observed for specimens that were negative for HPV. In ASCUS, low‐grade squamous intraepithelial lesion (LSIL), and high‐grade squamous intraepithelial lesion (HSIL) categories, the average number of HPV‐positive cells per slide was 19 cells, 127 cells, and 450 cells, respectively. The number of cells with a punctate staining, suggestive of HPV integration, was 21% in ASCUS, 34% in LSIL, and 46% in HSIL specimens.

CONCLUSIONS.

The results of the current study indicate positive correlations between the severity of the disease and the increased overall quantity of HPV‐positive epithelial cells in cervical cytology specimens and accumulation of cells with punctate staining suggestive of integrated HPV. In summary, the developed HPV‐CARD assay was found to provide novel information regarding the proportion and staining pattern of HPV‐infected epithelial cells in different cytologic categories of cervical specimens. Cancer (Cancer Cytopathol) 2007. © 2007 American Cancer Society.     

A validation study of the FocalPoint GS imaging system for gynecologic cytology screening

BACKGROUND:

Studies of the performance of the automated FocalPoint Guided Screening (FPGS) imaging system in gynecologic cytology screening relative to manual screening have yielded conflicting results. In view of this uncertainty, a validation study of the FPGS was conducted before its potential adoption in 2 large laboratories in Ontario.

METHODS:

After an intense period of laboratory training, a cohort of 10,233 current and seeded abnormal slides were classified initially by FPGS. Manual screening and reclassification blinded to the FPGS results were then performed. Any adequacy and/or cytodiagnostic discrepancy between the 2 screening methods subsequently was resolved through a consensus process (truth). The performance of each method's adequacy and cytodiagnosis vis‐a‐vis the truth was established. The sensitivity and specificity of each method at 4 cytodiagnostic thresholds (atypical squamous cells of undetermined significance or worse [ASC‐US+], low‐grade squamous intraepithelial lesion or worse [LSIL+], high‐grade squamous intraepithelial lesion or worse [HSIL+], and carcinoma) were compared. The false‐negative rate for each cytodiagnosis was determined.

RESULTS:

The performance of FPGS in detecting carcinoma, HSIL+, and LSIL+ was no different from the performance of manual screening, but the false‐negative rates for LSIL and ASC‐US were higher with FPGS than with manual screening.

CONCLUSIONS:

The results from this validation study in the authors' laboratory environment provided no evidence that FPGS has diagnostic performance that differs from manual screening in detecting LSIL+, HSIL+, or carcinoma. Cancer (Cancer Cytopathol) 2013;121:189–196. © 2013 American Cancer Society.     

Should LSIL‐H be a distinct cytology category?

BACKGROUND:

The 2001 Bethesda System for gynecologic cervical cytology reporting classifies squamous intraepithelial lesions into low‐grade (LSIL) and high‐grade (HSIL) lesions. An intermediate term, “low‐grade squamous intraepithelial lesion, cannot exclude high‐grade squamous intraepithelial lesion (LSIL‐H),” has been used in a small percentage of LSIL cases. To the authors' knowledge, little is known regarding the human papillomavirus (HPV) status in patients with LSIL‐H.

METHODS:

A total of 808 SurePath specimens obtained between December 2009 and April 2011 were tested for 40 HPV genotypes using DNA microarray, followed by a confirmatory DNA sequencing assay.

RESULTS:

The infection rate for high‐risk HPV in women with LSIL‐H (92%) was strikingly close to that for women with HSIL (91%), which was higher than that for those with LSIL (74%); atypical squamous cells, cannot rule out high‐grade lesion (ASC‐H) (78%); or LSIL and ASC‐H combined (74%). HPV type 16, the most common carcinogenic HPV genotype, was detected in 36% of women with LSIL‐H, which was significantly higher than that in women with LSIL and ASC‐H combined (13.8%), but less than that in women with HSIL (44.6%). Patients with LSIL‐H and HSIL had similar infection rates for low‐risk/intermediate‐risk HPV genotypes, which were lower than those in LSIL or LSIL and ASC‐H combined.

CONCLUSIONS:

Women found to have LSIL‐H on a Papanicolaou test appear to have a unique HPV distribution pattern that clearly differs from LSIL and is comparable to that for HSIL, suggesting an increased risk of high‐grade lesions over that of women with LSIL. Recognizing LSIL‐H as an independent diagnostic category may help in the early identification of the high‐risk subgroup that may require a management algorithm comparable to that for patients with HSIL. Cancer (Cancer Cytopathol) 2012. © 2012 American Cancer Society.     

Immunocytochemical colocalization of P16(INK4a) and Ki-67 predicts CIN2/3 and AIS/adenocarcinoma

BACKGROUND:

Although previous studies have shown that p16^INK4a and Ki‐67 are sensitive and specific markers for high‐grade lesions (≥CIN2) on cervical biopsies, limited information is available regarding the performance of a dual‐staining approach as a diagnostic adjunct in cervical cytology. We evaluated a dual p16^INK4a/Ki‐67 immunocytochemistry (ICC) assay to determine its sensitivity and specificity versus that of high‐risk HPV (HR‐HPV) in a US‐based pilot cytology study.

METHODS:

ThinPrep specimens from 122 cervical cytology specimens encompassing 23 negative (NILM), 20 ASC‐US, 22 LSIL, 17 ASCH, 22 HSIL, and 18 AGC cases were processed for multiplexed ICC staining using a CINtec Plus Kit. Dual‐positive assay results were defined based on the detection of 1 or more epithelial cells that were stained for both p16^INK4a and Ki‐67 without regard to cellular morphology. HR‐HPV testing was performed by multiplex PCR with capillary electrophoresis genotyping.

RESULTS:

Dual staining for p16^INK4a and Ki‐67 was frequently detected in HSIL and AGC but was rarely detected in NILM cases. The HR‐HPV assay showed a sensitivity of 76.2% and a specificity of 55.8% for the detection of clinically significant cervical squamous or endometrial lesions. In contrast, the colocalization of p16^INK4a plus Ki‐67 maintained a high sensitivity of 81.8% and improved specificity to 81.8% for biopsy‐confirmed CIN2/3, endocervical adenocarcinoma, or endometrial adenocarcinoma.

CONCLUSIONS:

Dual staining for p16^INK4a/Ki‐67 immunocytochemistry dramatically increased specificity and maintained high‐level sensitivity for the diagnosis of CIN2/3 or glandular lesions compared with PCR‐based testing for HR‐HPV. Cancer (Cancer Cytopathol) 2012. © 2011 American Cancer Society.     

Prevalence of High Grade Squamous Intraepithelial Lesion (HSIL) and Invasive Cervical Cancer in Patients with Low Grade Squamous Intraepithelial Lesion (LSIL) at Cervical Pap Smear

Objective: To assess the prevalence and factors associated with a histologic diagnosis of high grade squamous intraepithelial lesion (HSIL) and invasive cervical cancer in patients with low grade squamous intraepithelial lesion (LSIL) cervical pap smear findings. Methods: Medical records (including cytology reports, colposcopic impression, and pathologic results from cervical biopsy, endocervical curetting, cervical conization or hysterectomy) of 226 women with LSIL from conventional cervical pap smears during January 2001 to December 2005, who subsequently underwent colposcopic evaluation at our institution, were reviewed. Results: Mean age of the patients was 39.0 years. The incidences of LSIL, HSIL, microinvasive cervical cancer were 58.8%, 15.0%, 1.3% respectively. No associations were found between age, parity, contraception, anti-HIV or menstrual status and the detection of HSIL/invasive cervical cancer. Conclusion: Approximately 16.3 % of LSIL pap smear cases turn out to be HSIL or invasive cervical cancer from histologic diagnosis.     

Quantitative methylation‐specific PCR for the detection of aberrant DNA methylation in liquid‐based Pap tests

BACKGROUND.

Aberrant promoter methylation of selective tumor suppressor genes has been detected in squamous intraepithelial lesions (SIL) and invasive cervical cancer. Identification of methylation profiles of genes that can distinguish high‐grade SIL (HSIL) from low‐grade SIL (LSIL), and cytologically negative for intraepithelial lesion or malignancy (NILM) residual liquid‐based Papanicolaou (Pap) tests may be potentially useful as an ancillary test for cervical cancer screening.

METHODS.

Using real‐time quantitative methylation‐specific polymerase chain reaction (PCR) (QMSP), the authors analyzed the frequency and relative level of promoter methylation for DAPK1, IGSF4, SPARC, and TFPI2 in biopsy‐confirmed HSIL and LSIL, and NILM residual liquid‐based Pap tests. The percentage of methylation (%M) for each gene was calculated using the reference gene, ACTB. The cumulative methylation score for each sample, defined as the sum of %M of all 4 genes, was used to analyze the genes in combination.

RESULTS.

For each gene analyzed the frequency and relative level of methylation were increased in HSIL compared with combined NILM/LSIL samples. The cumulative methylation scores were significantly higher in HSIL samples (P < .0001). Area under the receiver operating characteristic (ROC) curve (AUC) demonstrated that methylation of each gene could distinguish HSIL from NILM/LSIL samples (AUC range, 0.6–0.67; P ≤ .0028). The combination of 4 genes showed improved test performance (AUC = 0.76; P < .0001). There was no significant difference in cumulative methylation in HSIL cases with histologic outcomes of cervical intraepithelial neoplasia grade 2 (CIN2) versus CIN3. There was no association between the methylation of any gene and the presence of human papillomavirus.

CONCLUSIONS.

The methylation profile of multiple genes in combination can better distinguish HSIL from combined NILM/LSIL samples. Although aberrant DNA methylation has the potential to function as a molecular biomarker of HSIL in liquid‐based Pap tests, additional genes that are selectively methylated in HSIL are needed to improve the clinical performance. Cancer (Cancer Cytopathol) 2008. © 2008 American Cancer Society.     

Pathology correlates of a Papanicolaou diagnosis of low‐grade squamous intraepithelial lesion,cannot exclude high‐grade squamous intraepithelial lesion

BACKGROUND.

The objective of this study was to compare findings after a cytologic report of low‐grade squamous intraepithelial lesion, cannot exclude high‐grade squamous intraepithelial lesion (LSIL‐H) with findings after a report of low‐grade squamous intraepithelial lesion (LSIL).

METHODS.

A review of patient records revealed that 312 women had cytologic findings of LSIL‐H, and 324 consecutive women in a comparison group had cytologic findings of LSIL during 2005. Findings over 6 months after diagnosis were retrieved and analyzed using chi‐square tests, Fisher exact tests, and independent group t tests.

RESULTS.

Histology was available for 194 of 312 women (64%) with LSIL‐H and for 184 of 324 women (57%) with LSIL. Of these, 47 of 194 women (24%) with LSIL‐H had grade 2 cervical intraepithelial neoplasia or greater (CIN2+) versus 13 of 184 women (7%) with LSIL (P < .0001). No cancers were identified. High‐grade SIL cytology was reported in 2 of 105 women who had LSIL (2%) and in 4 of 93 women who had LSIL‐H (4%). Women with LSIL‐H who were positive for CIN2+ were younger than those without CIN2+ (25 years vs 30 years; P = .0067)

CONCLUSIONS.

Clinicians whose laboratories report LSIL‐H should manage women who have LSIL‐H with colposcopy, whereas only serial cytologic surveillance is required after a report of LSIL. Cancer (Cancer Cytopathol) 2008. © 2008 American Cancer Society.     

Papanicolaou smear history in women with low‐grade cytology before cervical cancer diagnosis

BACKGROUND.

The purpose of the current study was to examine the screening histories of women diagnosed with invasive cervical cancer (ICC) in 2000 who had previous Papanicolaou (Pap) smears deemed to be unsatisfactory or with low‐grade findings that did not lead to biopsy.

METHODS.

A total of 252 Pap smears from 47 women taken between 1992 and 2000 were included in the study; 247 smears were reexamined at the laboratory of origin before the study and all 252 were then reexamined independently by 2 experienced cytotechnicians and 2 cytopathologists.

RESULTS.

Of the 47 cases of ICC, 35 were squamous cell carcinoma, 10 were adenocarcinoma, and 2 were other types. On reexamination at the laboratory of origin, 24 cases were upgraded and in the study group 27 cases were upgraded to diagnoses requiring biopsy. On reexamination at the laboratory of origin, it was found that the first high‐grade squamous intraepithelial lesion (HSIL) could have been diagnosed on average 4.2 years earlier than it was originally (95% confidence interval [95% CI], 3.3–5.1 years). On reexamination by the study group the first diagnosis of HSIL was made in smears dating from 5.4 years before the diagnosis of ICC (95% CI, 4.5–6.2 years).

CONCLUSIONS.

The study confirms that unsatisfactory and low‐grade Pap smears imply a risk of developing high‐grade lesions at a later date and shows that in a screening program a subgroup of smears may be diagnosed as unsatisfactory or low grade despite the presence of high‐grade findings that are detectable on reexamination. Cancer (Cancer Cytopathol) 2007. © 2007 American Cancer Society.     

The significance of high‐risk human papillomavirus detection in women aged ≥ 50 years with atypical squamous cells of undetermined significance cytologic preparations

BACKGROUND.

The use of high‐risk human papillomavirus (HRHPV) testing in the triage of women with a cytologic diagnosis of atypical squamous cells of undetermined significance (ASC‐US) has gained widespread acceptance. To date, very little has been reported on the significance of the detection of HRHPV in elderly women.

METHODS.

Results of HRHPV testing performed on women aged ≥50 years were examined for a 20‐month period. Reflex testing for HRHPV was performed on residual liquid‐based cytology specimens from women who were diagnosed with ASC‐US by using the Digene Hybrid Capture method. Follow‐up information on women who had HRHPV detected was obtained from subsequent pathology reports (cytology and surgical).

RESULTS.

HRHPV testing was performed on 762 specimens from women aged ≥50 years; virus was detected in 105 specimens (13.8%), and follow‐up was available in 63 of those women (60%). Follow‐up results included negative tests in 32 women (50.8% of those with follow‐up available), low‐grade squamous intraepithelial lesion in 26 women (41.3%), and high‐grade squamous intraepithelial lesion (HSIL) in 5 women (7.9%). No glandular neoplasia or invasive carcinoma was identified. Relative light units/cutoff (RLU/CO) values ranged from 1 RLU/CO to 1705 RLU/CO; no significant associations were identified between RLU/CO values and follow‐up results.

CONCLUSIONS.

Although HRHPV was detected in a minority of samples, HSIL was present in 7.9% of those with HRHPV. This confirms that the presence of HRHPV in women aged ≥50 years with ASC‐US specimens needs clinical follow‐up. There were no significant differences in RLU/CO values between women with positive versus negative follow‐up to allow for further discrimination for follow‐up. Cancer (Cancer Cytopathol) 2007. Published 2007 by the American Cancer Society.     

Performance of HPV DNA Testing with Hybrid Capture 2 in Triaging Women with Minor Cervical Cytologic Abnormalities (ASC-US/LSIL) in Northern Thailand

Background: Minor cervical cytologic abnormalities include atypical squamous cells of undeterminedsignificance (ASC-US) and low-grade squamous intraepithelial lesion (LSIL). Approximately 10-20% of womenwith minor cytologic abnormalities have histologic high-grade squamous intraepithelial or worse lesions (HSIL+).In Thailand, women with minor cytologic abnormalities have a relatively high risk of cervical cancer, and referralfor colposcopy has been suggested. A triage test is useful in the selection of women at risk for histologic HSIL+ toreduce the colposcopy burden. The aim of this study was to assess the performance of high-risk HPV DNA test intriage of women with minor cytologic abnormalities in northern Thailand. Materials and Methods: All womenwith ASC-US/LSIL cytology who were referred to our colposcopy clinic from October 2010 to February 2014were included. HPV DNA testing was performed using Hybrid Capture 2 (HC2). All patients received colposcopicexamination. Accuracy values of HC2 in predicting the presence of histologic HSIL+ were calculated. Results:There were 238 women in this study (121 ASC-US and 117 LSIL). The HC2 positivity rate was significantlyhigher in the LSIL group than in ASC-US group (74.8% versus 41.0%, p<0.001). Histologic HSIL+ was detectedin 9 women (7.4%) in the ASC-US group and 16 women (13.7%) in the LSIL group (p=0.141). There was nohistologic HSIL+ detected among HC2-negative cases (sensitivity and negative predictive value of 100%). Theperformance of HC2 triage was highest among women aged >50 years with ASC-US cytology. An increase in thecut-off threshold for positive HC2 resulted in a substantial decrease of sensitivity and negative predictive value.Conclusions: HPV DNA testing with HC2 shows very high sensitivity and negative predictive value in triage ofwomen with minor cervical cytologic abnormalities in northern Thailand. An increase of the cut-off thresholdfor HC2 triage is not recommended in this region.     

Adjunctive high‐risk human papillomavirus DNA testing is a useful option for disease risk assessment in patients with negative Papanicolaou tests without an endocervical/transformation zone sample

BACKGROUND.

Current guidelines recommend that women with negative Papanicolaou (Pap) test results and no endocervical/transformation zone (EC/TZ) sample return for screening within 12 months. For some women, this represents earlier follow‐up than advocated in several routine screening guidelines. Controversy remains with regard to the correlation between sampling of the EC/TZ, Pap test quality, and disease risk assessment.

METHODS.

A retrospective study was conducted reviewing the results from 143,438 liquid‐based cervical Pap tests performed at a large academic women's hospital between July 2005 and December 2006. Vaginal Pap tests were excluded from the study. Women with any Pap result, women with low–grade squamous intraepithelial lesions (LSILs), and patients with high–grade squamous intraepithelial lesion (HSIL) Pap test results were stratified by 10‐year age groups and according to the presence or absence of an EC/TZ sample (EC/TZS). Women with LSIL and HSIL Pap test results with and without an EC/TZS were also compared for rates of high–risk human papillomavirus (hrHPV) DNA detection.

RESULTS.

Of the total of 143,438 cervical Pap tests performed, 27,359 (19.1%) were reported to be lacking an EC/TZS. The absence of an EC/TZS was found to be highest in adolescents and in mature women aged ≥50 years. The overall detection rate of LSIL was 4.29% and that of HSIL was 0.64%. Both the LSIL and HSIL rates were found to be significantly higher in Pap tests with an EC/TZS compared with Pap tests without an EC/TZS (LSIL: 4.51% vs 3.37% and HSIL: 0.72% vs 0.29%). However, when women with LSILs and HSILs were divided into a group in which EC/TZS was present and a group in which EC/TZS was absent, no significant differences were found to be present with regard to hrHPV DNA rates between the 2 groups.

CONCLUSIONS.

Adjunctive hrHPV DNA testing is effective in stratifying risk for the presence of SIL in women with and without an EC/TZS. This finding is consistent with recently reported data from >9000 patients with negative Pap results, which found that hrHPV DNA–positive test rates are independent of the presence or absence of an EC/TZS. hrHPV DNA results provide a useful new optional adjunctive tool for the objective stratification of disease risk in women with negative Pap tests and no EC/TZS. Cancer (Cancer Cytopathol) 2008. © 2008 American Cancer Society.     

Immunohistochemical detection of p16INK4a in liquid‐based cytology specimens on cell block sections

BACKGROUND

Colposcopy biopsy procedure is a standard recommendation for atypical squamous cell cannot exclude high‐grade lesion (ASC‐H) in abnormal Papanicolaou smears. p16 (p16INK4a), a cell cycle regulator, has been shown to be overexpressed in squamous dysplasia. To further improve the diagnostic accuracy of the ASC‐H Papanicolaou smear and to reduce unnecessary procedures, the authors evaluated the utility of immunodetection of p16 in liquid‐based cytology specimens on cell blocks.

METHODS

Seventy‐five liquid‐based (SurePath; TriPath Imaging, Inc. Burlington, NC) cytology specimens were prepared for cell blocks. Three groups (G1, G2, and G3) of cases were included: G1 comprised 44 cases of ASC‐H; G2, 14 cases of high‐grade dysplasia; and G3, 17 negative/reactive cases. All cases in G1 were confirmed by cervical biopsy or Digene Hybrid Capture 2 (Digene, Gaithersburg, Md) human papilloma virus (HPV) testing. Immunodetection for p16 was performed on cell blocks.

RESULTS

In G1, 26 of 44 (59%) cases showed squamous dysplasia, with 14 high‐grade squamous intraepithelial lesion (HSIL) cases. Twenty‐two of 28 (79%) p16‐positive cases were confirmed by surgical biopsy or HPV testing, with a diagnostic sensitivity of 85%, specificity of 67%, positive predictive value (PPV) of 79%, and negative predictive value (NPV) of 75%. Four cases with false‐negative staining for p16 were identified. All 28 cases of HSIL (14 from G1 and 14 from G2) were positive for p16.

CONCLUSIONS

1) p16 is a sensitive marker to confirm the diagnosis of ASC‐H on a cell block; 2) Multiple unstained slides with adequate cellularity can be obtained from each cell block; and 3) Additional markers can be used to further increase diagnostic sensitivity and specificity. Cancer (Cancer Cytopathol) 2007. © 2007 American Cancer Society.     

Usefulness of liquid-based cytology specimens for the immunocytochemical study of p16 expression and human papillomavirus testing: a comparative study using simultaneously sampled histology materials

BACKGROUND: In cervical lesions, the overexpression of p16 is reported to be closely associated with high-risk human papillomavirus (HPV) infection. The objective of the current study was to confirm the usefulness of liquid-based cervical specimens for p16 staining as well as tissue sections. METHODS: A total of 98 patients with cervical lesions were entered into the current study. After the cytologic examination using liquid-based cervical smears, the same slides were immunostained for p16 and were compared with slides of simultaneously obtained, immunohistologically stained tissue sections. Moreover, the status of the HPV infection was examined by polymerase chain reaction using residual cytologic samples. RESULTS: Using liquid-based Pap smears, 98 cases were diagnosed as atypical squamous cells of undetermined significance (38 cases), low-grade squamous intraepithelial lesion (12 cases), high-grade squamous intraepithelial lesion (HSIL) (33 cases), and invasive carcinoma (15 cases). The concordance rate between the cytologic and histologic diagnoses was found to be higher in high-grade lesions compared with low-grade lesions. Immunohistochemistry revealed that all HSIL and invasive carcinoma cases contained p16-positive cells in the liquid-based Pap smears and diffuse p16 staining was observed in all high-grade lesions with greater than CIN Grade 3 cervical intraepithelial neoplasia except for two adenocarcinoma cases. Of the 98 cases, 60 were found to be positive for high-risk HPV and 55 of these 60 HPV-positive cases were found to be p16 positive on cytologic examination. There were 16 cases that demonstrated marked discrepancies between the cytologic and histologic diagnoses. CONCLUSIONS: The results of the current study confirmed that the immunohistochemical detection of p16 was more sensitive and specific than HPV status in cervical lesions using a liquid-based method as well as tissue samples, suggesting that p16 should be used as a satisfactory biomarker for the primary screening of cervical cytology.     

Diagnostic value of p16INK4A,Ki‐67, and human papillomavirus L1 capsid protein immunochemical staining on cell blocks from residual liquid‐based gynecologic cytology specimens

BACKGROUND:

This study was conducted to evaluate the reliability and role of cell block preparations in the diagnosis of neoplastic and preneoplastic lesions of the cervix and to improve the value of cell block preparations in diagnosing and predicting the prognosis of cervical lesions through immunostaining of p16INK4A (p16), Ki‐67, and human papillomavirus (HPV) L1 capsid protein (HPV L1).

METHODS:

In total, 138 specimens were diagnosed on liquid‐based cytology (LBC) and cell block preparations, and 63 specimens were subjected subsequently to tissue follow‐up and immunostaining for p16, Ki‐67, and HPV L1 on cell block sections.

RESULTS:

In 42 specimens that were diagnosed as low‐grade squamous intraepithelial lesion, high‐grade squamous intraepithelial lesion (HSIL), and squamous cell carcinoma (SCC) on cell blocks, 38 specimens (90.5%) were confirmed by histopathologic reports, and there was slightly better than 81.6% agreement between LBC and tissue follow‐up. Immunointensity and cells that were positive for p16 were enhanced according to increased pathologic grade and differed statistically between cervical intraepithelial neoplasia 1 (CIN‐1) and CIN‐2/CIN‐3 as well as SCC. The positive rates of HPV L1 decreased gradually according to the severity of cervical neoplasia, and HPV L1/p16 expression patterns were related to the severity of cervical lesions.

CONCLUSIONS:

The cell block preparation technique was complementary to LBC, and the authors concluded that the application of LBC combined with cell block preparations may improve the diagnostic accuracy of cytology. Immunostaining for p16 and Ki‐67 on cell block preparations can help to improve the diagnostic accuracy of HSIL and SCC. A combined expression pattern of p16 and HPV L1 may serve as a valuable index for predicting prognosis and follow‐up of cervical dysplastic lesions. Cancer (Cancer Cytopathol) 2010. © 2010 American Cancer Society.     

Accuracy of liquid‐based cytology

BACKGROUND:

In the New Technologies for Cervical Cancer Screening (NTCC) randomized controlled trial, no significant increase in the sensitivity of liquid‐based cytology (LBC) was observed compared with conventional cytology. Both were interpreted by cytologists who had limited previous LBC experience. The objective of the current study was to assess whether different results could be expected with experienced LBC interpreters.

METHODS:

A stratified, random sample of 818 LBC slides from the NTCC study was obtained. These slides were reviewed blindly and independently by 3 international experts who did not participate in the NTCC. The sensitivity and specificity of external experts were estimated for cervical intraepithelial neoplasia grade 2 or greater (CIN2+) and for CIN3+ histology, and the differences were compared with the sensitivity and specificity of the original cytologic interpretation using cutoffs of atypical squamous cells of undetermined significance (ASCUS) and low‐grade squamous intraepithelial lesion (LSIL).

RESULTS:

With the endpoint of CIN2+ histology, the difference in sensitivity between external experts and the original interpretation was ?5.3 (95% confidence interval [CI], ?16.0 to 5.4) with ASCUS as the cutoff and 3.8 (95% CI, ?8.2 to 15.8) with LSIL as the cutoff. External experts had slightly lower specificity using ASCUS as the cutoff (?3.4; 95% CI, ?3.9 to ?2.9) and LSIL as the cutoff (?0.7; 95% CI, ?1.0 to ?0.4).

CONCLUSIONS:

The accuracy of the external experts' interpretation was similar to that of the original interpretation. Therefore, the current results indicated that LBC is not expected to increase sensitivity even if it is used by interpreters who have extensive experience with this technique. Cancer (Cancer Cytopathol) 2010. © 2010 American Cancer Society.     

Image‐guided ThinPrep Papanicolaou tests and cotesting with high‐risk human papillomavirus in women aged 30 years and older in a low‐risk private practice population

BACKGROUND:

Screening for cervical cancer precursors has evolved considerably with the introduction of new technologies to improve the early detection of disease. The objective of this study was to analyze the accuracy and effectiveness of combined screening with cytology and high‐risk human papillomavirus (HR‐HPV) testing in a low‐risk population of women aged ≥30 years.

METHODS:

Consecutive unselected samples from a group of 1871 women aged ≥30 years were screened with image‐guided ThinPrep tests and HR‐HPV tests during a 6‐month period. Histologic follow‐up was reviewed among women with positive HR‐HPV tests.

RESULTS:

A total of 85 (4.5%) women had positive HR‐HPV tests. In 48 HR‐HPV–positive women with follow‐up biopsies, 41 (85%) were found to have histologic abnormalities. Thirty‐three (1.9%) women with cytologically normal Papanicolaou (Pap) tests harbored HR‐HPV, and a cervical intraepithelial neoplasia (CIN) 2+ lesion was detected in 1 (16%) of 6 women with histologic follow‐up. Conversely, 2 (28%) of 7 women with high‐grade intraepithelial lesion on cytology tested negative for HR‐HPV during the same period. A case of serous carcinoma with atypical glandular cells on cytology was also negative for HR‐HPV, as expected.

CONCLUSIONS:

In this low‐risk population of women aged ≥30 years, histology‐confirmed CIN2+ lesions were identified in women with negative cytology and positive HR‐HPV tests, as well as in those with positive cytology and negative HR‐HPV tests. Because both cytology and HPV testing alone missed significant lesions, cotesting with Pap and HR‐HPV in women aged ≥30 years appears to be a reasonable option in a low‐risk population. (Cancer Cytopathol) 2009. © 2009 American Cancer Society.