Can we improve the positive predictive value of atypical glandular cells not otherwise specified?

Atypical glandular cells and predictive features of malignancy in Pap smears: A retrospective monocentric study

OBJECTIVE

The introduction of cytological screening with the Papanicolau smear significantly reduced cervical cancer mortality. However, Pap smear examination can be challenging, being based on the observer ability to decode different cytological and architectural features. This study aims to evaluate the malignancy rate of AGC (atypical glandular cells) category, investigating the relationships between cytological and histological diagnosis.

METHODS

Eighty-nine patients, diagnosed as AGC at cytological evaluation and followed up with biopsy or surgical procedure at Policlinico Gemelli Hospital, Rome, Italy, were included in the study. The cytopathological architectural (feathering, rosette formation, overlapping, loss of polarity, papillary formation, three-dimensional formation) and nuclear (N/C ratio, nuclear enlargement and hyperchromasia, mitoses, nuclei irregularity, evident nucleoli) features of AGC were evaluated. Statistical analyses were performed to assess cyto-histological correlation and determine the relevance of architectural and nuclear features in the diagnosis of malignancy.

RESULTS

Of the 89 AGC patients, 48 cases (53.93%) were diagnosed as AGC-NOS and 41 (46.07%) were diagnosed as AGC-FN, according to the Bethesda classification system. The follow-up biopsies or surgical resections revealed malignancy in 46 patients (51.69%). The rates of malignancy for AGC-NOS and AGC-FN were 35.41% and 70.73% respectively. Furthermore, analysing cytopathological features, we found that both architectural and nuclear criteria were statistically significant (p < 0.05). Only overlapping, nuclear irregularity and increased N/C ratio were not found to be statistically significant for detecting malignancy.

CONCLUSIONS

Cytological diagnosis of glandular lesions remains a valid tool, when appropriate clinical correlation and expert evaluation are available.

Cytologic Parameters in Predicting the Outcome of Atypical Glandular Cells on Papanicolaou Smears: A Single-Institutional Experience

Background

Atypical glandular cells (AGCs) diagnosis on Pap (Papanicolaou) smears are uncommon and may represent various benign and malignant lesions.

Objective

This study aims to report the incidence of AGC on Pap smear, to study the relationship of AGC with malignancy, and to determine cytomorphological features that help in predicting malignancy.

Materials and Methods

Retrospective analytical study conducted in the Department of Oncopathology at Tertiary Cancer and Research Institute. In this retrospective study, we included cases diagnosed with AGC between July 2017 to July 2022. All slides were reviewed and subclassified according to the Bethesda 2014 classification system (TBS). The predetermined cytomorphological features observed in the smears were recorded. The follow-up histopathological diagnoses of the cases were retrieved. The significant cytomorphological and clinicopathological findings for malignancy were determined.

Results

Pearson χ2 test with SPSS software version 22 to compare cytologic features of cases with benign and malignant follow-up. The significant cytomorphological features observed in neoplastic cases were cells in 3-dimensional clusters, nuclear overlapping, reniform nucleus, irregular nuclear membrane, increased nuclear size, single macronucleoli, engulfed neutrophils, and prominently vacuolated cytoplasm.

Conclusions

The diagnosis of AGC on cytology is associated with clinically significant lesions, and cytomorphologic parameters can be used to predict the benign and malignant outcome.

False-Positive Atypical Endocervical Cells in Conventional Pap Smears: Cyto-Histological Correlation and Analysis

INTRODUCTION

Endocervical glandular atypia is relatively rarely diagnosed by Pap smears. A significant proportion of follow-up histological samples show no premalignant or malignant lesions. The observed cytomorphological findings in premalignant glandular lesions overlap with histologically proven reactive lesions.

METHODS

A total of 45 conventional Pap smears diagnosed as atypical endocervical cells, not otherwise specified (AEC, NOS) with human papillomavirus (HPV) status available were blindly evaluated in a search for 38 cytomorphological features representing background, architectural, cellular, and nuclear features. Of the cases, 30 represented histologically proven benign changes, and 15 represented histologically proven adenocarcinoma in situ (AIS) or endocervical adenocarcinoma (EAC) cases. The benign biopsies were re-evaluated, and the associations of the cytomorphological features or combinations of them with specific histological features and entities were statistically examined.

RESULTS

The most frequent histological findings in the benign group were squamous metaplasia, inflammation, tubal metaplasia, and microglandular hyperplasia. The statistical analysis revealed cytological features associated with squamous metaplastic changes, inflammation, and microglandular hyperplasia. Unfortunately, no cytomorphological feature was sufficiently specific to confidently leave the lesion without follow-up and histological correlation. Degeneration and nuclear crowding were the most salient features that distinguished the instances of glandular atypia with benign follow-up histology from those with histologically proven AIS or EAC (26.7 vs. 60.0%, p = 0.030, and 50.0 vs. 86.7%, p = 0.017).

CONCLUSION

Additional methods besides cytomorphology are required to reliably distinguish smears with AEC, NOS harbouring only benign histological changes from those exhibiting endocervical glandular malignancy.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endocervical Cytology: Inter- and Intra-Observer Variability in Conventional Pap Smears

INTRODUCTION

Although the cytological diagnostic criteria for cervical squamous and glandular lesions are established by the Bethesda System for Reporting Cervical Cytology, the reproducibility of the diagnosis of these lesions has been shown to be variable in previous studies. At best, occasional good kappa (κ) values were reached both inter- and intra-observerly. Generally, consensus on high-grade lesions has been better compared to milder changes.

METHODS

Altogether, 167 conventional Pap smears from 50 patients with histologically confirmed endocervical adenocarcinomas (EAC) and adenocarcinomas in situ (AIS) and from 28 patients with histologically proven high-grade intraepithelial lesions were analyzed by four cytopathologists. Twenty of the smears were later re-evaluated by the same cytopathologists. κ-values between cytopathologists in the categories of squamous versus glandular, negative for intraepithelial lesion or malignancy (NILM), atypical, and preneoplastic/neoplastic were calculated. The diagnostic Pap smears of EAC and AIS with best and worst consensus between observers were then morphologically analyzed.

RESULTS

The reproducibility ranged from poor to substantial. The overall κ-values between the four cytopathologists were 0.412, 0.314, 0.272, and 0.082, respectively, in the categories of preneoplastic/neoplastic, squamous versus glandular, NILM, and atypical. Overall intra-observer κ-values were correspondingly 0.491, 0.616, 0.345, and 0.241. In the diagnostic smears of AIS and EAC, the nuclear size >2 times the normal and nuclear pleomorphism were the commonest features associated with good diagnostic consensus and the lack of nuclear enlargement and degenerative changes were associated with poor consensus.

CONCLUSIONS

The reproducibility of preneoplasia/neoplasia diagnoses was better than that of atypia and NILM both in the inter- and intra-observer part in this study. In the smears from AIS and EAC patients, general neoplasia-associated features were more common in samples with good agreement by the four cytopathologists of the neoplastic nature and the endocervical origin of the lesion.

Atypical glandular cells in Papanicolaou test: Which is more important in the detection of malignancy, architectural or nuclear features?

OBJECTIVE

Atypical glandular cells (AGCs) in Pap (Papanicolaou) smears are uncommon but may represent various benign and malignant lesions. The aim of this study was to evaluate the AGC incidence in Pap smears, analyse the relationship between AGC and malignancy, and reveal the importance of architectural and nuclear features observed cytologically in malignancies.

METHODS

Patients diagnosed with AGC on the basis of cervicovaginal cytology between May 2011 and July 2018 were included in this study. All slides were retrospectively reviewed and subclassified according to the Bethesda 2001 classification system. The cytomorphological features observed in the smears were recorded. Cytohistological correlations were evaluated, and the significant clinicopathological findings for malignancy were determined.

RESULTS

Of 87 536 Pap smears, 195 (0.22%) had AGC results and 156 had tissue follow-up. Among the 156 smears with AGC, 80 (51.3%) were diagnosed as AGC-NOS (atypical glandular cells, not otherwise specified) and 76 (48.7%) as AGC-FN (atypical glandular cells, favour neoplastic). Follow-up biopsies revealed benign pathologies in 49 cases (31.4%) and malignant pathologies in 107 (68.6%). The rate of malignancy observed in AGC-FN cases (89.5%) was higher than the rate of malignancy in AGC-NOS cases (48.8%). Among the cytomorphological features, nuclear irregularity, presence of macronucleoli, feathering, loss of polarity, papillary pattern, and three-dimensional formation were found to be significant indicators of malignancy.

CONCLUSION

As AGC in Pap smear was associated with a clinically significant diagnosis in 68.6% of the cases in our study, we suggest that all patients with AGC should undergo further clinical assessment.

The role of Pap smear in the diagnostics of endocervical adenocarcinoma

In the high-income countries, the amount of cervical adenocarcinomas is on the rise. The pap smear sampling has a low sensitivity and a low specificity for endocervical malignancies, and there are only a few cytomorphological features, that are specifically associated with glandular atypia. In this study, 298 pap smears of 60 patients with endocervical adenocarcinoma or adenocarcinoma in situ (AIS) and 30 patients with high-grade intraepithelial lesion (HSIL) in histology were reviewed. The pap smear type (screening/clinical), the HPV status and the time from sampling to the histological confirmation of diagnosis were recorded for each case. Despite that no cytomorphological features could be associated with adenocarcinoma statistically, 70% of the pap smears were initially correctly diagnosed as an endocervical glandular lesion. Palisading cell borders, nuclear pleomorphism and the lack of single atypical cells present simultaneously were found to be associated with adenocarcinoma and AIS with the corresponding ORs of 5.89 (95% CI 1.96-17.70), 3.71 (95% CI 1.14-12.02) and 10.76 (95% CI 1.20-59.50). This combination of features was seen in smears taken up to 5 years before the histological diagnosis. Of all our screening samples, 10.9% were HPV-positive. There were no HPV-negative samples among patients with adenocarcinoma.

Cytologic parameters predicting neoplasia in Papanicolaou smears with atypical glandular cells and histologic follow-up: a single-institution experience

INTRODUCTION

Studies investigating histologic follow-up of The 2001 Bethesda System diagnosis of atypical glandular cells (AGC) have focused on various screening methods, patient populations, and Papanicolaou preparations. Our aim was to report the histologic follow-up of AGC diagnoses from ThinPrep slides and evaluate specific cytologic features predicting benign or malignant follow-up results.

MATERIALS AND METHODS

A retrospective search identified liquid-based cervical cytology results interpreted as AGC. AGC diagnoses were stratified into four groups: atypical endometrial cells (AGC-EM); atypical endocervical cells (AGC-EC); AGC, favor neoplastic (AGC-FN); and AGC not otherwise specified (AGC-NOS). Evidence of disease was based on histologic follow-up (biopsy or resection specimen) with a diagnosis of cancer, complex endometrial hyperplasia, or high-grade squamous dysplasia. Available slides were blindly reviewed for specific cytologic features. Statistical analysis compared cytologic factors that would predict benign or malignant follow-up.

RESULTS

We interpreted 264 samples as AGC from 2005 through 2009. Of the 246 (93.2%) with follow-up histologic material, 60 (24.4%) were AGC-EM; 36 (14.6%) were AGC-EC; 28 (11.4%) were AGC-FN; and 122 (49.6%) were AGC-NOS. Neoplasia was diagnosed in 80 (32.5%). Neoplastic cases showed significantly increased numbers of single cells, cells in 3-dimensional clusters, engulfed neutrophils, nuclear enlargement, increased nuclear-to-cytoplasmic ratio, irregular nuclear borders, reniform nuclei, loss of polarity, and macronucleoli.

CONCLUSIONS

Cytologic parameters can be used to predict benign from neoplastic glandular lesions. Biopsy follow-up is necessary to correlate cytologic findings when AGC is diagnosed on a Papanicolaou smear.

Expression and utility of IMP3 in the differential diagnosis of atypical glandular cells and adenocarcinoma in liquid-based cervical cytology

BACKGROUND

Atypical glandular cell (AGC) interpretation in gynecological cytopathology presents many diagnostic challenges. We evaluated the expression of IMP3 in liquid-based cervical cytology and its utility in differentiating premalignant/malignant glandular lesions from benign/reactive processes. Additionally, we tried to determine whether IMP3 may be useful in differentiating among the types of uterine adenocarcinomas.

DESIGN

Our cohort included 82 cases; 59 diagnosed with AGC and 23 with adenocarcinoma (Ac). IMP3 immunocytochemical stain was performed on ThinPrep slides and the results correlated with subsequent biopsy findings. IMP3 positivity was assessed by strong (2+ and 3+) granular cytoplasmic staining in at least one group of three epithelial cells.

RESULTS

In the AGC group, IMP3 was positive in 14 (73.7%) of 19 cases that on histologic follow-up were confirmed Ac, and 39 (98.6%) of 40 non-glandular lesions/benign cases were negative. In the Ac group, IMP3 was expressed in 16 (69.6%) of 23 cases, of which 16 (72.2%) of 21 were uterine Ac. By combining the two groups, and excluding the 2 extrauterine carcinomas, IMP3 was positive in 30 (75%) of 40 uterine Ac, most of which (86.7%) were in situ/invasive endocervical Ac, and type II endometrial Ac (Papillary Serous and Clear Cell Carcinoma), and only 40% endometrioid Ac.

CONCLUSION

In ThinPrep slides with AGC, IMP3 positivity predicts the presence of a significant endocervical or endometrial lesion on subsequent histology, and may also be a potential diagnostic tool useful in differentiating among the types of adenocarcinomas of the female lower genital tract.