Significance of cervicovaginal cytology after radiation therapy for cervical carcinoma

Cervical cytology: Radiation and other therapy effects

The different treatment options for carcinoma cervix include radiation, chemotherapy, and surgical treatments. Cytological analysis of smears is crucial for patient follow-up to determine response to therapy and to diagnose the persistence or recurrence of malignancy. Anatomical alterations and changes in cell morphology following radiation or chemotherapy make collecting and interpreting cervical cytology samples difficult. These issues can be mitigated by liquid-based cytology. Ionizing radiation is used in radiotherapy (RT) to kill cells. It is important that cytologists are aware of alterations in morphology of the cells. Radiation can cause cytoplasmic and nuclear changes. Cellular enlargement, vacuolation, granularity loss, and other changes linked with cell death are examples of cytoplasmic alterations. Nuclear enlargement and multinucleation are the most frequent nuclear alterations. These changes are determined by the amount of time that has passed since radiation. It should be emphasized that no one characteristic is pathognomonic. Post-irradiation dysplasia is a condition described as abnormal cellular changes in non-neoplastic epithelial cells after RT. Chemotherapy causes comparable alterations as radiation but impacts fewer cells. Busulfan and other chemotherapeutic treatments may produce morphological alterations, which cytologists must be aware of and able to identify. Immunosuppressive treatments, hormonal therapy, and tamoxifen are some of the other drugs that might cause changes in cervical morphology. Surgical methods used in the detection and treatment of cervical cancer may potentially cause alterations as a result of thermal damage and healing. For the treatment of cervical lesions, electrocautery and the loop electrosurgical excisional procedure are available. These procedures employ electric current ablation leading to ischemic changes in the cervical smear. Cytological analysis of smears following treatment with these modalities necessitates a comprehensive history, kind of therapy, and duration of treatment.

Role of vault cytology in follow-up of hysterectomized women: results and inferences from a low resource setting

The study was undertaken to assess the utility of cervico-vaginal/vault cytology in the follow-up of women treated for cervical cancer and benign gynecological conditions. Records of 3,523 cervico-vaginal smears from 2,658 women who underwent hysterectomy and/or radiotherapy or chemotherapy, over a 10-year period were retrieved. Data was collected on type of treatment received, indication for hysterectomy, age of patient, presenting symptoms, stage of tumor, interval since treatment, cytology and biopsy results. The results of cytology versus other parameters were analyzed separately for women treated for cervical cancer and those hysterectomized for benign indications. Malignant cells were detected in 141/1949 (7.2%) follow-up smears from treated cervical cancer cases (140 recurrences and 1 VAIN). Around 92% of recurrences of cervical cancer were detected with in 2 years of follow-up and 75% of these women were symptomatic. Cytology first alerted the clinicians to a recurrence in a quarter of cases. On the other hand, VAIN was detected in 5/1079 (0.46%) vault smears from 997 women hysterectomized for benign gynecologic disease. All these women were asymptomatic and majority (80%) were detected in follow-up smears performed between 3 and 10 years. Vault cytology is an accurate tool to detect local recurrences/VAIN in women treated for cervical cancer or benign gynecological conditions. It may even first alert the clinicians to a possibility of recurrence. However, due to extremely low prevalence of VAIN/vaginal cancer, it seems unwarranted in women hysterectomized for benign indications, especially in resource constrained settings.

Cytologic–histologic correlation of screening and diagnostic Papanicolaou tests

The Pap test (PT) is most commonly used as a screening test; however, it is often also used as a "diagnostic test," usually in patients of known or suspected lesions. As we have recently shown that the yield of atypical interpretations in diagnostic Pap tests (DPTs) is nearly five times greater than the yield for screening Pap tests (SPTs), we speculated that the PT might function differently when used in each population. The University of Virginia's cytologic-histologic correlation results for PTs, accessioned between 4 January 2003 and 11 December 2003, were reviewed. PTs were considered as SPTs or DPTs, depending on the billing codes used by referring physicians. Using the original diagnosis, results were compared for SPTs and DPTs using chi-square testing. There were 1,311 PTs (776 DPTs and 535 SPTs), which had histologic follow-up within a 7-mo period. Of SPTs interpreted as negative (242), 11 (4.5%) showed SIL or worse and 3 (1.2%) showed HSIL or worse on follow-up biopsy. Of SPTs interpreted as ASC (133), 59 (44.3%) showed SIL or worse and 16 (12.0%) showed HSIL or worse on follow-up biopsy. Of SPTs interpreted as LSIL (117), 65 (55.5%) showed SIL or worse and 17 (14.5%) showed HSIL or worse on follow-up biopsy. Of SPTs interpreted as HSIL (38), 31 (81.6%) showed SIL or worse and 23 (60.5%) showed HSIL or worse on follow-up biopsy. Of SPTs interpreted as glandular lesions (AGC, adenocarcinoma, etc.) (4), 3 (75%) showed HSIL or malignancy. Of DPTs interpreted as negative (261), 69 (26.4%) showed SIL or worse and 10 (3.8%) showed HSIL or worse on follow-up biopsy. Of DPTs interpreted as ASC (166), 75 (45.2%) showed SIL or worse and 22 (13.3%) showed HSIL or worse on follow-up biopsy. Of DPTs interpreted as LSIL (227), 146 (64.4%) showed SIL or worse and 31 (13.7%) showed HSIL or worse on follow-up biopsy. Of DPTs interpreted as HSIL (119), 105 (87.4%) showed SIL or worse and 84 (70.6%) showed HSIL or worse on follow-up biopsy. Of DPTs interpreted as glandular lesions (AGC, adenocarcinoma, etc.) (3), 3 (100%) showed HSIL or malignancy. Overall, DPTs were more likely than SPTs to show SIL or HSIL on follow-up biopsy (P < 0.01), and negative DPTs were more likely than negative SPTs to show SIL or HSIL on follow-up biopsy (P < 0.01, P = 0.01, respectively). Some of this may be a reflection of the increased percentage of LSIL and HSIL results for DPTs. Despite the difference in disease prevalence between women having SPTs and those having DPTs, the PT seems to function relatively the same in both scenarios, except in high risk women with negative DPTs.

Interpretive yields of screening Pap tests and diagnostic Pap tests

Recently, our laboratory has introduced the Medicare classification "diagnostic Papanicolaou (Pap) test" (DPT) for both conventional and liquid-based Pap tests. Because little is known regarding the diagnostic yield of DPT, we review our experience with these tests in a community with a low incidence of squamous intraepithelial lesions and contrast this with our experience with screening Pap tests (SPTs). A search of our laboratory's computerized data system identified all Pap tests classified as SPT and DPT from December 3, 2002 to December 2, 2003. The interpretations were tabulated and statistical comparisons were made. Between December 3, 2002 and December 2, 2003 63,626 Pap tests were interpreted (57,922 SPTs and 5704 DPTs). DPTs were far more likely to yield abnormal results (atypical squamous cells or worse, P<0.001) and were especially more likely to yield malignant results. These differences have numerous possible implications regarding screening, rescreening, and the design of studies that investigate the screening value of the Pap test.

Liquid-based cytology for the postirradiation surveillance of women with gynecologic malignancies

OBJECTIVE

To determine the performance of liquid-based cytology using ThinPrep in the postirradiation surveillance of women with gynecologic malignancies.

METHODS

Patients with endometrial and cervical cancer treated with primary or adjuvant radiotherapy between 2000 and 2002 were identified. Details regarding tumor characteristics, treatment, and cytologic and histologic results were abstracted. Binomial variables were compared with the chi-square test. The performance characteristics of liquid-based cytology were evaluated.

RESULTS

A total of 302 liquid-based cytologic samples from 121 women were evaluated. Overall, 294 (97.4%) of the specimens were adequate for interpretation and 132 (44.9%) were within normal limits. Benign cellular changes, including benign radiation changes, were identified in 141 (47.6%). Atypical squamous cells (ASCUS) were found in 15 (5.1%), recurrent dysplasia in 4 (1.3%), and recurrent carcinoma in 2 (0.7%). Follow-up of the 15 ASCUS smears revealed 13 (86.7%) normal smears and 2 cases of squamous intraepithelial lesions. Benign findings were noted in three of the four smears with SIL. The sensitivity for the detection of SIL was 33%, the specificity 99%, and the positive predictive value (PPV) 25%. Of the 4 patients with local recurrences, 2 were detected by cytology. The sensitivity for the detection of recurrent carcinoma was 50%, with a specificity and PPV of 100%.

CONCLUSIONS

ThinPrep for the surveillance of women with gynecologic malignancies treated with radiotherapy is associated with a high rate of satisfactory samples and a low rate of equivocal and ASCUS cytology.

Prognostic significance of DNA cytometry of postirradiation cervicovaginal smears

BACKGROUND

Cytologic sampling is performed routinely after radiotherapy for cervical carcinoma. The prognostic significance of postirradiation dysplastic and atypical cells is uncertain because of difficulties in distinguishing preneoplastic and cancerous changes from benign radiation changes. DNA cytometry studies may provide a more objective method of identifying significant lesions.

METHODS

Postirradiation cervical carcinoma patients with cervical/vaginal smears containing atypical or dysplastic cells were identified prospectively. Papanicolaou smears were destained, restained with a Feulgen stain, and evaluated for DNA content using image cytometry. Pathologic and clinical records were monitored on each patient for evidence of recurrence or biopsy-proven dysplasia.

RESULTS

Of 46 patients, 14 had been diagnosed on cytology as having atypical squamous cells, 4 as having atypical/suspicious cells, 12 with low grade squamous intraepithelial lesions (SIL), 3 with high grade SIL, and 13 with ungraded SIL. DNA histograms were classified as follows: 14 diploid, 19 polyploid, and 13 aneuploid. Cytologic diagnosis and histogram type were correlated significantly and both correlated with clinical outcome. The probability of either postirradiation dysplasia or recurrence was as follows: SIL, 82%; suspicious, 100%; polyploid, 79%; and aneuploid, 92%. Patients with atypical squamous cells of undetermined significance or diploidy most frequently had negative follow-up (57% each). All patients with both SIL and aneuploidy developed either dysplasia or recurrence. The stage of disease did not correlate with outcome or histogram pattern.

CONCLUSIONS

DNA analysis of postirradiation cytologic smears demonstrating atypia or dysplasia may provide useful ancillary information. The presence of aneuploidy usually signifies either recurrence or dysplasia. Polyploidy most frequently occurs in dysplastic processes, whereas diploid histograms usually denote a benign disease course.

Chronic radiation effects: a correlative study of smears and biopsies from the cervix and vagina

Cervicovaginal smears and biopsies from patients treated with radiotherapy for cervical carcinoma were examined morphologically and immunochemically to provide information on the tissue derivation of cells characteristic of chronic radiation effect in postirradiation smears. In biopsies, stromal changes, such as fibrosis, vessel changes, and atypical fibroblasts were most common. Ulceration, leucocytic infiltration, multinucleated giant cells, regenerative epithelium, and atypical glandular epithelial cells were also present in some specimens. These changes were reflected in smears collected from the same patients, where multinucleated giant cells, repair cells, and large atypical cells were often present. Correlation of smears and biopsies suggest that repair cells are collected from areas of epithelial regeneration and glandular radiation atypia. Sampling of ulcerative or eroded tissue may produce smears with multinucleated giant cells, atypical stromal cells, endothelial cells, and numerous macrophages. Correct recognition of these cell types and smear patterns may assist in avoiding false positive diagnoses.

Radiation and chemotherapy injury: pathophysiology, diagnosis, and treatment

The text in general is not meant to represent the participants' entire presentations. The lecture presenters in general are not responsible for the summaries, and cannot necessarily be assumed to agree with all that is stated, but they deserve credit for providing the lecture and handout material on which the summaries are based, and in most cases have contributed far more to the summaries than I have.

DNA cytometry in postirradiation cervical-vaginal smears

Benign radiation change (BRC) in cervical-vaginal smears may be difficult to distinguish from postirradiation dysplasia (PRD) or recurrent cervical carcinoma. The utility of DNA analysis in postirradiation smears was evaluated retrospectively in 71 patients. Representative Papanicolaou smears were restained with a Feulgen method and 100 to 250 cells were analyzed for DNA content using the CAS 200 image analysis system. Thirty-three control irradiated patients had negative smears with a minimum 3-year follow-up. Thirty controls (91%) had diploid histograms with a mean coefficient of variation of 8.2% and an average of 6.8% of cells in S and G2/M phase. Three control patients had atypical nondiagnostic histograms. Twenty-three patients had abnormal smears and subsequent local recurrence; 21 (91%) had abnormal histograms, with seven showing polyploidy and 14 showing aneuploidy. The remaining 15 patients had abnormal smears diagnosed as PRD but no evidence of recurrent carcinoma. Five were polyploid, six were aneuploid, one was diploid, and three were atypical but nondiagnostic. Interactive DNA cytometry is useful in differentiating BRC from PRD and recurrent cancer. Aneuploidy is rarely, if ever, seen in negative smears with BRC. However, BRC may be associated with broad diploid peaks and increased proliferating cells. An abnormal histogram can be seen with PRD and does not always correlate with recurrent disease.

Post-irradiation cytology of cervical cancer patients

The accuracy of cervicovaginal cytology following radiotherapy for cervical cancer is compromised by the anatomical and tissue changes resulting from irradiation. Collection of representative samples may be more difficult, and benign radiation changes, post-irradiation dysplasia, and the frequent occurrence of repair cells and active stromal cells in post-irradiation smears may cause diagnostic problems. Nevertheless, cytology is a valuable tool for the detection of locally recurrent cervical cancer. It is simple and economical to perform at the time of clinical follow-up examination, and may detect occult tumour recurrence. Awareness of the cellular changes resulting from irradiation, and the varied composition of post-irradiation smears may lead to more accurate interpretation of the cytological findings.

The accuracy of cervicovaginal cytology in the detection of recurrent cervical carcinoma following radiotherapy

The accuracy of cervicovaginal cytology testing in the detection of recurrent cervical carcinoma was investigated by correlating clinical and histology records with cytology smear results for two groups of patients. All patients had been treated with radiotherapy, with or without pelvic surgery, for carcinoma of the uterine cervix. Abnormal cervicovaginal smear results were present for 45.7% (32/70) of patients with histologically diagnosed recurrent cervical carcinoma including a correct prediction of recurrent cervical carcinoma in 32.8% (23/70) of cases. A cytologic diagnosis of recurrent carcinoma was present for 48.9% (23/47) of cases with local recurrence. The positive predictive value for a histologic diagnosis of recurrent cervical carcinoma after a positive cytology report for a group of 61 patients was estimated to be 98.4%. A cytologic diagnosis of locally recurrent cervical carcinoma preceded clinical signs in 15/61 (24.6%) of cases. These results indicate that although cervicovaginal cytology after radiotherapy for cervical cancer does not have high sensitivity it is a reliable test for the diagnosis of local recurrence. Cytologic examination of the vaginal vault or cervix after treatment may thus provide an early diagnosis of tumor recurrence or persistence, in some cases prior to the onset of clinical signs.

Radiation changes in endocervical cells in brush specimens

Although the cytologic changes in cervical and vaginal squamous cells after radiation therapy were well-described decades ago, alterations in endocervical cells in response to radiation therapy have not been delineated in detail. We studied the effect of radiation therapy (usually combined linear accelerator beam and radium insertion) on endocervical cells as seen in endocervical brush specimens from 24 patients treated for cervical cancer. Of the 40 smears examined, 45% were taken 3-6 mo after the completion of radiotherapy, 28% at 10-14 mo, and 20% at 18-34 mo. Endocervical cells appeared as single cells and in clusters and had lavender, mucin-filled cytoplasm. When present in clusters, they lacked the honeycomb appearance of normal endocervical cells. In smears taken at 3-6 mo, the majority of endocervical cells were enlarged (100% of smears) but they usually had normal nuclear/cytoplasmic ratios. Their nuclei were enlarged (100% of smears); varied in size (100%); had some coarse chromatin (67%) and large nucleoli (78%); and were multinucleated (89%). Repair cells and multinucleated histiocytes were seen in 83% and 61% of smears, respectively. Each of these cytologic findings was less apparent in follow-up smears taken more than 6 mo after the completion of radiation therapy. Awareness of these cytologic changes in endocervical cells after radiation therapy precludes the overdiagnosis of cancer in follow-up endocervical brush specimens.

Sequential radiation changes in cytology of vaginal smears in carcinoma of cervix uteri during radiotherapy

The study deals with acute/immediate radiation changes in 2020 sequential vaginal smears in 101 patients of carcinoma of the cervix uteri, 97 were of squamous cell carcinoma and 4 of adenocarcinoma. The smears were collected after 12-14 days, 15-24 days and 25 days to 6 weeks following radiotherapy. The pretreatment vaginal smears were collected and examined for percentage of cancer cells. Subsequent smears were studied for radiation changes in benign and malignant cells, such as cell size, vacuolation of cytoplasm, multinucleation and nuclear changes, etc. A gradual and linear decline in cancer cells was observed until the end of therapy; 41.6% of patients had less than 10% cancer cells within 12-14 days of therapy, 63.4% of patients between 15 and 24 days and 74.6% after 25 days to 6 weeks following radiation. Eighty three percent of the patients attained zero level at the end of therapy.

Radiation-induced atypia. A review

A review of radiation-induced atypia is presented. The radiation changes are divided into acute, intermediate, and late. The presence of cancer cells following irradiation is divided into persistent carcinoma, early recurrent carcinoma, and late recurrent carcinoma. The features of each group are described, supplemented by illustrations depicting the changes. The cytologic changes of radiation are discussed by correlating the light microscopic features with the electron microscopic findings in 8 cases that were studied ultrastructurally.

The value of colposcopy in follow-up care of the treated gynecologic oncology patient

The diagnostic value of colposcopy for primary gynecologic malignancies is well accepted. This study was conducted to determine the value of colposcopy in follow-up examinations of treated gynecologic oncology patients. The original gynecologic malignancies included carcinomas of the cervix, endometrium, ovary, vulva, vagina, fallopian tubes, and uterine sarcomas. Distinct colposcopic changes could be identified secondary to radiation therapy, granulation tissue, surgery, and recurrent disease. One-hundred eight treated gynecologic oncology patients were colposcopically examined. Twenty-four of the one-hundred eight patients developed recurrent disease. Thirteen of twenty-four patients had recurrent disease in the vagina, on the cervix, or the vulva. The recurrent disease in these 13 patients was colposcopically diagnosed.

Radiation changes in vaginal and cervical cytology in carcinoma of the cervix uteri

Radiation changes are observed in all postirradiated smears of squamous cell carcinoma of the cervix from 56 females, although to a variable degree. After 1 year the changes subside gradually. A high cornification index is a good guide for recurrence. The significance of dysplastic cells as premonition for recurrence is debatable. The presence of malignant cells at any stage was considered of grave significance, and indicates poor radiation response or recurrence.