Artifactual endocervical atypia induced by endocervical brush collection

The abnormal glandular smear: cytologic prediction, colposcopic correlation and clinical management

We reviewed recent cytological reporting of abnormal glandular cells on cervical smears in order to assess the predictive value of these reports and the contribution of colposcopy in the assessment of these abnormalities. The study consisted of a 5-year retrospective review of the clinical management of 80 women with abnormal glandular cells on a cervical smear, with clinical and histopathological data available for review in the interval 1992-1996. There were two groups of women: (i) those referred with gynaecological symptoms and (ii) those with screen detected abnormalities who were asymptomatic and significantly younger than the first group. The predictive value of a glandular smear for malignancy was 42.5% and for premalignancy 28.8%. The most common lesions detected were cervical intraepithelial neoplasia (CIN) (13), endometrial cancer (13), cervical adenocarcinoma (10) and cervical intraepithelial glandular neoplasia (CIGN) (8). Four cases of endometrial carcinoma presented through screening. In the remainder a variety of benign conditions were identified as responsible for the abnormal smear. Failure to find an explanation for the abnormal smear only occurred in 8.8%. In developing a protocol for abnormal glandular smears, our observations indicate that: (a) those with abnormal bleeding require endometrial sampling; (b) for those with screen detected abnormality, colposcopy is valuable as it is a sensitive predictor of early invasion and can predict glandular abnormality; (c)diseases of the entire genital tract, non-gynaecological viscera and metastatic cancer can generate cytological abnormality; (d) screen detected borderline abnormality in endocervical cells is associated with CIN III.

Evaluation and significance of hyperchromatic crowded groups (HCG) in liquid-based paps

OBJECTIVE

Hyperchromatic crowded groups (HCG), a term first introduced into the cytology literature by DeMay in 1995, are commonly observed in Pap tests and may rarely be associated with serious but difficult to interpret lesions. In this study, we specifically defined HCG as dark crowded cell groups with more than 15 cells which can be identified at 10x screening magnification.

METHODS

We evaluated consecutive liquid-based (Surepath) Pap tests from 601 women (age 17-74 years, mean age 29.4 yrs) and observed HCG in 477 cases. In all 477 HCG cases, Pap tests were found to be satisfactory and to contain an endocervical sample. HCG were easily detectable at 10x screening magnification (size up to 400 um, mean 239.5 um) and ranged from 1 to 50 (mean 19.5) per Pap slide.

RESULTS

HCG predominantly represented 3-Dimensional groups of endocervical cells with some nuclear overlap (379/477--79%), reactive endocervical cells with relatively prominent nucleoli and some nuclear crowding (29/477--6%), clusters of inflammatory cells (25/477--5.2%), parabasal cells (22/477--4.6%), endometrial cells (1/477--0.2%). Epithelial cell abnormalities (ECA) were present in only 21 of 477 cases (4.6%). 18 of 21 women with HCG-associated ECA were less than 40 years old; only 3 were = or > 40 years. HCG-associated final abnormal Pap test interpretations were as follows: ASCUS (6/21--28%), LSIL (12/21--57%), ASC-H (2/21--9.5%), and HSIL/CIN2-3 (3/21--14%). The association of HCG with ECA was statistically significant (p = 0.0174. chi-square test). In patients with ECA, biopsy results were available in 10 cases, and 4 cases of biopsy-proven CIN2/3 were detected. Among these four cases, HCG in the Pap tests, in retrospect represented the lesional high grade cells in three cases (one HSIL case and two ASC-H cases). Interestingly, none of the 124 cases without HCG were found to have an epithelial cell abnormality.

CONCLUSION

We conclude: a. HCG are observed in a high proportion of cervical smears. b. In the vast majority of cases, HCG are benign. c. ECA were only observed in cases with HCG. This observation is consistent with the hypothesis that the presence of HCG in Pap tests most often represents adequate sampling of the transformation zone, thus increasing the chances of detecting an epithelial cell abnormality. d. Only a few cases with HCG were associated with a serious ECA, but careful scrutiny of all HCG appears warranted to avoid the potential diagnostic pitfall of a significant false negative interpretation.

Adenocarcinoma in situ of the uterine cervix

BACKGROUND

Little attention has been given to the reasons for failure to detect adenocarcinoma in situ (AIS) of the uterine cervix in Papanicolaou (Pap) smears. In the current study, the authors examined a series of screening or diagnostic errors in cases in which the final histologic diagnosis was either AIS or AIS combined with a high-grade squamous intraepithelial lesion (AIS + HSIL).

METHODS

Smears obtained in the 3 years before histologically proven AIS or AIS + HSIL was diagnosed and within a specified 6-year period (1993-1998) were reviewed and reclassified. All were conventional Pap smears. The smears studied were those with a review diagnosis of possible or definite high-grade epithelial abnormality that initially were reported by a cytotechnologist to be negative (screening error) or that were reported by a pathologist to be negative, unsatisfactory, or indicative of a low-grade epithelial abnormality (diagnostic error). A semiquantitative, blinded assessment of the frequency of cytologic criteria for the diagnosis of AIS was made for smears with erroneous diagnoses compared with a series of smears that yielded true-positive findings.

RESULTS

Sampling errors, which were defined as cases in which smears did not have sufficient evidence for a diagnosis of possible or definite AIS or HSIL on review, accounted for 35.1% and 36% of all smears from patients with a biopsy diagnosis of AIS and patients with a biopsy diagnosis of AIS + HSIL, respectively. With regard to AIS, there were 3 screening errors and 5 diagnostic errors, accounting for 10.4% of 77 smears. Minimal, poorly preserved material was evident in four smears, including three smears with only one sheet of abnormal glandular cells. In four other smears, there was a moderate amount of adequately preserved glandular material, mainly in large sheets, with varying degrees of crowding and hyperchromasia. With regard to AIS + HSIL, there were 6 screening errors and 6 diagnostic errors, accounting for 13.5% of 89 smears. In those smears, there generally was a moderate amount of abnormal material in the form of crowded groups of suboptimally preserved, hyperchromatic squamous cells. Only two of those smears yielded findings of possible abnormal glandular cells. Only 3 of 20 errors occurred in smears that were examined during the last 3 years of the study. In the semiquantitative assessment, smears with erroneous findings were shown to contain far less abnormal material than true-positive smears and to exhibit a corresponding paucity of diagnostic criteria.

CONCLUSIONS

Sampling errors were the main cause of false-negative reports in cases of AIS and AIS + HSIL. The primary factors that contributed to screening or diagnostic errors in AIS were minimal, poorly preserved abnormal material and an overly conservative approach to the assessment of unusual large sheets or aggregates of glandular cells. With regard to AIS + HSIL, most laboratory errors were related to the presence of crowded groups of squamous epithelial cells. There were fewer errors in the last 3 years of the study, raising the possibility of improvement over time.

Cytologic features of high-grade squamous intraepithelial lesions involving endocervical glands on ThinPrep cytology

Usage of liquid-based cytology has resulted in better cellular preservation with enhancement of nuclear features. The purpose of this retrospective 2-yr study (January 1999 through December 2000) was to evaluate the cellular features of endocervical gland involvement by a high-grade squamous intraepithelial lesion (HSIL) vs. endocervical adenocarcinoma in situ (AIS) on cell samples processed by the ThinPrep method as compared to conventional smears. Of the 97 cases of CIN III diagnosed on cytology, 52 (54%) showed surface endocervical gland involvement by CIN III and form the basis of this study. There were also six cases of endocervical AIS diagnosed on histology with prior cytology. The architectural features of HSIL involving endocervical glands and AIS were similar to those previously reported on conventional smears. A consistent finding of HSIL involving endocervical glands was the loss of central cell polarity and piling within cell groups, a finding not present in AIS. Central cell polarity was maintained in cellular groupings of AIS. In addition to the cellular feature present on conventional smears, micronucleoli were clearly visualized in cells of HSIL involving endocervical glands and prominent nucleoli were present in AIS. Apoptosis and mitoses were clearly visualized in both entities. Endocervical gland involvement by HSIL has characteristic cell patterns and features on liquid-based/thin-layer cytology that permit their distinction from AIS.

Abnormal cervicovaginal smears due to endometriosis: a continuing problem

Endometriosis may be challenging when identified on cervicovaginal smears (CVS), leading to an incorrect interpretation of high-grade squamous intraepithelial lesion (HSIL), or atypical glandular cells of undetermined significance (AGUS) including adenocarcinoma in situ (AIS). Awareness of cervical endometriosis, particularly in predisposed patients, is crucial for a correct diagnosis. While cervical endometriosis has been reported to be a diagnostic pitfall of glandular abnormalities, its characteristic features are still not well-established. This may partially be attributed to the varied cytomorphologic features endometriosis shows, depending on menstrual cycle hormonal changes. We describe our experience with three examples where CVS were interpreted as either AGUS or HSIL, which led to a hysterectomy in 2 of 3 patients. Cervical endometriosis needs to be considered with other well-known benign conditions that mimic glandular abnormalities, including cervicitis, tubal metaplasia, lower uterine segment sampling, and microglandular hyperplasia. Published series and our own experience lead us to suggest that these smears will continue to present diagnostic difficulties.

Endocervical reactive atypia: a histologic-cytologic study

Of 1,500 cervical tissue specimens, 27 cases showed histologic changes of reactive glandular atypia which we defined as endocervical cells with large hyperchromatic, often irregular nuclei, which did not fulfill the criteria for endocervical adenocarcinoma. Eighteen of these 27 cases had preceding or concurrent cervico-vaginal smears. Six of these showed cells which were similar to those seen in histologic sections. The cytologic characteristics of these cells are defined. To determine if atypia is related to inflammatory-regenerative changes, 29 cases of endocervical polyps were examined, of which 11 showed histologic changes of endocervical reactive atypia; 4 showed these changes cytologically as well. Twenty-eight cases of routine hysterectomy specimens were examined, of which 2 cases showed endocervical reactive atypia, which indicated that the atypical changes were indeed reactive. Nine out of 27 cases were associated with hormonal usage. Fourteen cases were associated with squamous intraepithelial lesions or evidence of human papilloma virus. Follow-up of our 27 index cases revealed no progression to adenocarcinoma. These findings indicate that atypia, as we define it, of the endocervix can be due to inflammatory-reparative changes or possibly related to hormonal usage, and permit its separation from precursor lesions of endocervical adenocarcinoma.

A clinical review of borderline glandular cells on cervical cytology

OBJECTIVE

To review the diagnoses and diagnostic pathway of women presenting with borderline glandular cells on cervical cytology. To outline the basis of clinical approach of these women.

DESIGN

Retrospective review.

POPULATION

Forty-three women referred to the hospital department over a 32-month period.

METHODS

Review of the casenotes for the demographic data, previous cervical cytology and/or histology report, indication for the smear resulting in borderline glandular cells, colposcopic findings, diagnostic and/or treatment procedures, final diagnosis and current status.

RESULTS

The average age was 36.7 years. Twenty-four women (56%) had clinically significant lesions: seven women (16%) presented with cancers, of which one was endometrial in origin, and 17 (40%) with intraepithelial neoplasia (CIN and cervical glandular intraepithelial neoplasia (CGIN)). Sixty-seven percent of all clinically significant lesions were of squamous origin. Thirty-seven had histological diagnosis, while six went on to cytological surveillance. Colposcopy was the most significant predictor for clinically significant lesions (P < 0.05). Punch biopsies and loop excisions were diagnostic when based on abnormal colposcopic findings. Brush cytology was appropriate follow up for asymptomatic, premenopausal women with no colposcopic abnormality. In addition, endometrial sampling was recommended in the peri- and postmenopausal women.

CONCLUSION

Borderline glandular cells have a high incidence of clinically significant lesions. Immediate referral for colposcopy and assessment is strongly recommended in women with two borderline glandular smears to avoid delays in potential cancer diagnosis.

The "Inconclusive--possible high grade epithelial abnormality" category in Papanicolaou smear reporting

BACKGROUND

The Australian Terminology for Cervical Cytology Reporting includes the category "Inconclusive-Possible high grade epithelial abnormality."

METHODS

The frequency of use of this category, the types of associated cell patterns, and the yield of high grade lesions at biopsy were studied.

RESULTS

One hundred and two cases categorized as "Inconclusive" were reported between January and June 1995, representing 0.24% of 41,712 Papanicolaou (Pap) smears screened. The abnormal cells were reported as squamous in 74.5% of cases, endocervical in 4.9% of cases, endometrial in 3.9% of cases, and indeterminate in 16.7% of cases. The main cellular patterns included disorganized groups of hyperchromatic squamous, glandular, or indeterminate cells (64.2% of cases) and atypical metaplastic squamous cells (28.4% of cases). Cell preservation was suboptimal. In 25.3% of cases the cells were highly degenerate or air-dried. Follow-up included biopsy (84.3% of cases), colposcopy alone (7.8% of cases), and repeat Pap smears without any detected abnormality (3.9% of cases). No follow-up was available in 3.9% of cases. High grade abnormalities were found in 66.3% of the biopsied cases and 55.9% of the total cases (48 cervical intraepithelial neoplasia [CIN] of Grade 2 or 3; 2 squamous cell carcinomas; 3 endocervical adenocarcinoma in situ [ACIS]; 3 adenocarcinomas of endocervical, ovarian, and endometrial origin; and 1 endometrial stromal sarcoma). In 16.2% of cases a low grade squamous lesion was present on biopsy (CIN, Grade 1 or human papillomavirus effect); and no lesion was found in 17.4% of cases.

CONCLUSIONS

The "Inconclusive" category was not overused, and gave a high yield of biopsy abnormalities. Accepting uncertainty in the diagnosis of some high grade lesions reduces their likelihood of being classified incorrectly as reactive changes, ignored because of poor cell preservation, or lost in the larger group of classifications such as atypical cells of undetermined significance, borderline nuclear abnormality, or non-specific minor changes.

Cytological aspects of uterine cervical adenocarcinoma, adenosquamous carcinoma and combined adenocarcinoma-squamous carcinoma: appraisal of diagnostic criteria for in situ versus invasive lesions

This paper reports the cytological findings based on air-dried smears in a retrospective series of 143 cases of endocervical adenocarcinoma, combined adenocarcinoma-squamous carcinoma and adenosquamous carcinoma drawn from the files of the BC Cancer Registry. Cervical cytology smears were available before biopsy in 131 patients, but in 18 cases the cytology showed no abnormality. Malignant changes or high-grade atypia of glandular and/or squamous cells (defined as moderate or severe dyskaryosis) were detected in 103 cases. In 46 cases, only a high-grade squamous abnormality was detected. Low-grade glandular and/or squamous lesions were detected in nine cases and one showed atypical endometrial-type glands. The cervical smears of 64 cases were reviewed in detail to determine the important cytomorphological criteria of in situ and invasive adenocarcinoma in air-dried smears, the technique used for preparing PAP smears in British Columbia. Endocervical cells were absent in four cases. Numerous (> 10) groups of glandular cells were present in 51 cases. Important clues to the diagnosis of adenocarcinoma included crowding of nuclei, stratification of nuclei, loss of polarity, syncytial balls and papillary groups of glandular cells, nuclear enlargement, nuclear pleomorphism, and the presence of free-lying atypical glandular cells. Nuclear hyperchromatism, chromatin pattern, nuclear borders, nuclear membranes, and numbers and morphology of nucleoli were not helpful criteria in our material. Criteria enabling reliable distinction between in situ and invasive adenocarcinoma and/or mixed adenocarcinoma-squamous carcinoma could not be established.

Microglandular endocervical hyperplasia and tubal metaplasia: pitfalls in the diagnosis of adenocarcinoma on cervical smears

The detection of atypical glandular cells of undetermined significance (AGUS) has risen recently due to the use of new endocervical canal sampling devices, in particular the cytobrush. From April 1993-June 1994, a diagnosis of AGUS ranging from adenocarcinoma in situ (AIS) to invasive adenocarcinoma was initially made on cervical smears from 6 women for whom histologic follow-up data were available. The purpose of this study was to determine if benign cervical glandular lesions can be reliably distinguished from adenocarcinoma on cytology. Review of the smears and histologic slides from 3 patients showed microglandular endocervical hyperplasia on cervical cone specimens. Cervical smears from 2 of these patients showed clusters of small-to-medium-sized cells with nuclei containing coarse, granular chromatin and prominent nucleoli. Cytoplasmic vacuoles and engulfment of neutrophils were present, findings suggestive of endometrial adenocarcinoma. The third patient's smear showed clusters of large cells with ample, vacuolated cytoplasm and vesicular nuclei containing prominent nucleoli, findings suggestive of endocervical adenocarcinoma. In 3 cases evaluated by cervical conization, histologic slides showed tubal metaplasia. The cervical smears showed clusters and sheets of cells with round-to-oval-shaped nuclei containing evenly distributed, finely granular chromatin and inconspicuous nucleoli. Pseudoglandular formation was present in 2 cases, a finding suggestive of AIS. Since the cytologic features of microglandular endocervical hyperplasia and tubal metaplasia overlap those of adenocarcinoma, a differential diagnosis is prudent on cytologic smears of AGUS.

Endocervical glandular atypia: a "new" problem for the cytologist

New patterns of cellular presentation on cervical smears have become more frequent since the introduction of new sampling devices which provide increased material from the upper portions of the endocervical canal. The normal histologic variability of the endocervical canal, as well as the presence of tubal metaplasia, infectious and inflammatory reactions, squamous lesions involving endocervical glands, and true endocervical neoplastic lesions in these areas, have presented the cytologist with a variety of cellular appearances which may cause difficulties in differential diagnosis. Recognition of these entities, their cytologic manifestations, and the effects of increased high endocervical sampling, will allow the cytologist to begin the process of gaining the experience necessary to assess these new cellular patterns. A potential management protocol for patient follow-up is presented which will allow the user to investigate such cases in an efficient and cost effective manner.

Artifactual endocervical atypia induced by endocervical brush collection

The cytologic distinctions between artifactual atypia induced by endocervical brush collection, endocervical glandular repair, and endocervical glandular dysplasia or neoplasia are often difficult. This difficulty is amplified by the lack of accepted cytologic criteria for endocervical glandular dysplasia, and the fact that earlier studies defining the significant cytologic features of endocervical adenocarcinoma in situ and endocervical adenocarcinoma (endocervical neoplasia) utilized a swab for endocervical cell retrieval. With the almost universal adoption of the endocervical brush, it is important to redefine those cytologic characteristics that differentiate true endocervical glandular dysplasia or neoplasia from reactive or reparative processes and instrument artifact. From our data, it appears that the classically described cytologic discriminators between a negative smear and smears of endocervical dysplasia or neoplasia are basically unchanged with some minor modifications for endocervical brush-collected samples.