Atypical glandular cells of undetermined significance on cervical smears. A study with cytohistologic correlation

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.

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.

Detection and Outcome of Endocervical Atypia in Cytology in Primary HPV Screening Programme

Most endocervical adenocarcinomas (EAC) are associated with high-risk HPV (hrHPV) infection, with HPV genotypes 16, 18 and 45 accounting for >90% of the cases. Among endocervical glandular lesions, screening with hrHPV test has previously shown to predict the outcome better than cytology, although around one-fifth of the EAC remain negative both in hrHPV testing and cytology. The study consists of two consecutive HPV-primary screening rounds, conducted in 2012–2015 and 2017–2020. Of the 87 women aged 35 to 60 years of age diagnosed with Atypical endocervical cells, NOS or Atypical endocervical cells, favor neoplastic cytology during the first screening round, 63 (72.4%) were hrHPV positive and 24 (27.6%) were hrHPV negative. Among hrHPV positive patients, three EAC, two adenocarcinomas in situ (AIS), one AIS + high-grade intraepithelial lesion (HSIL) and 13 HSIL were found. Of the histologically verified lesions, 68.4% (13/19) were purely of squamous origin. All the EAC and AIS were HPV16 or HPV 18 positive. No high-grade histological lesions were found among the hrHPV negative patients with cytological glandular atypia. A later database search revealed one HPV-negative, gastric-type mucinous EAC that was missed by the HPV primary screening.

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.

Clinicopathological Characteristics of Atypical Glandular Cells Determined by Cervical Cytology in Japan: Survey of Gynecologic Oncology Data from the Obstetrical Gynecological Society of Kinki District, Japan

BACKGROUND

The purpose of this study was to clarify the clinicopathological characteristics of, and the clinical approach used to identify, atypical glandular cells (AGCs) in Japan based on cervical cytology screening.

OBJECTIVES

This study included 1,254 patients with AGCs who underwent cervical cytology.

METHOD

Data from patients with AGCs were used to examine the practical management of AGCs and the histological results.

RESULTS

The incidence of AGCs was 0.20% (1,254/614,791). The 1,254 AGC cases included 859 endocervical cells not otherwise specified (NOS), 3 glandular cells NOS, 91 endocervical cells favor neoplasia (FN), and 301 atypical endometrial cells (AEMCs). Among the 1,254 AGC patients, the histological diagnosis was benign in 666 (53.1%), cervical intraepithelial neoplasia (CIN) 1 in 60 (4.8%), CIN2 in 31 (2.5%), CIN3 in 52 (4.1%), squamous cell carcinoma in 19 (1.5%), adenocarcinoma in situ in 39 (3.1%), cervical adenocarcinoma in 106 (8.5%), endometrial carcinoma in 209 (16.7%), ovarian cancer in 26 (2.1%), other malignancy in 4 (0.3%), and other under follow-up in 42 (3.3%). When the 1,254 AGC patients were divided into three medical intervention degrees according to histology, AGC-NOS, AGC-FN, and AEMC required no medical intervention in 78.7, 13.2, and 25.9% (678, 12, and 78) of the patients, cervical cone resection in 13.0, 9.9, and 0.3% (112, 9, and 1) of the patients, and radical laparotomy for invasive cancer in 8.3, 76.9, and 73.8% (72, 70, and 222) of the patients, respectively.

CONCLUSIONS

Our histological results supported the medical interventions applied for AGC diagnosis and treatment. AGC cases require careful histological evaluation.

Atypical glandular cells and cervical cancer: systematic review

Atypical glandular cells are a common finding in cervical cytology in cervical cancer screening and its occurrence has increased in the last decades. The identification of these cells is clinically very important due to its association with cervical and endometrial dysplasic lesions and cancer. Using a systematic approach, this article reviewed studies investigating cervical lesions that are characteristic in patients previously diagnosed as having atypical glandular cells. Studies in which diagnostic investigation did not include histopathological diagnosis were excluded. A comprehensive search for available material in LILACS, SciELO, PubMed/ Medline and Old Medline databases, dated between 1966 and 2009 was performed. Articles omitted by the electronic database search were also included. Nineteen articles met the inclusion criteria and were selected. This report aims at evaluating whether atypical glandular cells, initially found in cervical cytology and subsequently identified at the histological analysis, are related to the presence of benign, pre-malignant and malignant lesions. Eleven out of 19 selected articles showed the highest correlation between atypical glandular cells with benign diseases and six with squamous pre-malignant lesions.

The association of breast disease and atypical glandular cells on cervical cytology

OBJECTIVE

This study seeks to determine whether an association exists between atypical glandular cells (AGC) on cervical cytology and breast disease.

METHODS

We analyzed 470,147 Papanicolaou test results from January 1, 2002, to November 17, 2008, inclusive. We studied all cases of AGC versus a control group with normal Papanicolaou test results. The database was then searched to determine which of these women had a history of breast disease. A comparison of the prevalence of breast disease between the two groups was performed.

RESULTS

Of the 470,147 total Papanicolaou tests, 1,087 cases of AGC (0.23%) were identified from 1,026 women. There were 1,064 women comprising the normal population. The mean ± SD age of these two groups was 44.9 ± 13.7 and 41.6 ± 14.4 years, respectively. Among the women with an AGC on Papanicolaou testing, 40 (3.9%) had breast disease compared with 21 (2.0%) among those without an AGC on Papanicolaou testing (P = 0.009). Among the 40 women with an AGC on their Papanicolaou test and breast disease, 7 (17.5%) also had a concerning gynecologic (Gyn) pathologic finding at the level of the cervix, endocervix, or uterus. In comparison, the women with normal Papanicolaou test results had no Gyn pathologic findings.

CONCLUSIONS

The prevalence of an abnormal Gyn pathologic finding in those with AGC is consistent with prior data. Women from this data set who have an AGC on Papanicolaou testing have a statistically higher likelihood of having concurrent breast disease. Further data are needed to elucidate the reason for this association.

Clinical significance of atypical glandular cells on cervical cytology

OBJECTIVE

To evaluate the prevalence and histologic outcomes of patients with atypical glandular cells of undetermined significance (AGUS), diagnosed by Pap test, and concurrent risk factors.

DATA SOURCES

A PubMed/MEDLINE/Ovid HealthStar search of the English literature was conducted from January 1988 through March 2004.

METHODS OF STUDY SELECTION

The search criteria included the terms "atypical glandular cells of undetermined significance," "AGUS," or "AGC." All studies investigating the clinical significance of patients with an AGUS Pap test were included, except for those where consecutive Pap tests were not studied. Diagnostic outcomes were then determined.

TABULATION, INTEGRATION, AND RESULTS

Of the 916 studies identified, 24 met our inclusion criteria. Of the 2,389,206 Pap tests included in these studies, 6,829 (0.29%) had AGUS. Follow-up was available for 3,890 tests. These data showed the following rates of pathology: 8.5% low-grade squamous intraepithelial lesions (LSIL), 11.1% high-grade squamous intraepithelial lesions (HSIL), 2.9% adenocarcinoma in situ, 1.4% endometrial hyperplasia, and 5.2% malignancy. The most common malignancies were endometrial adenocarcinoma (57.6%), cervical adenocarcinoma (23.6%), ovarian and fallopian tube carcinoma (6.4%), squamous cell carcinoma of the cervix (5.4%), and other (6.9%). Of the AGUS Pap tests, the remaining 71.0% corresponded to benign findings, including reactive changes, polyps, and normal histology. Patients with AGUS, which favors a neoplastic process, or with a concurrent ASCUS have a greater likelihood of disease.

CONCLUSION

Histologic diagnosis showed that 29.0% of these Pap tests had findings requiring follow-up or therapeutic intervention, including a 5.2% rate of malignancy. Based on these findings, 99.6% of the diagnoses are within the region of surveillance when AGUS Pap tests are evaluated with colposcopy and directed biopsy, endocervical curettage, an endometrial biopsy in patients with risk factors for endometrial cancer, and pelvic examination.

Clinical utility of atypical glandular cells (AGC) classification: Cytohistologic comparison and relationship to HPV results

OBJECTIVES

To determine the utility of the category of atypical glandular cells (AGC) in the management of patients with putative cervical neoplasia and to correlate HPV-DNA test results when available.

METHODS

The Johns Hopkins Hospital cytopathology records of 50,668 women patients were searched for all liquid-based gynecologic cytology (LBP) results of Atypical Glandular cells of Undetermined Significance (AGUS) and AGC from January 1, 2001 through December 31, 2003, yielding 98 patients (0.19%). Oncogenic HPV-DNA tests were performed on the residual fluids of 43 of these patients, 37 of whom had follow-up biopsy. During the period of January 1, 2000 and December 31, 2002, we identified 237 patients (0.58%) with conventional Pap smears in the AGUS or AGC category, among 41,024 conventional smears collected contemporaneously. To avoid confusion in this paper, AGC will be used to replace those results that originally were AGUS.

RESULTS

Following the 98 LBP AGC interpretations, 24 lesions (33.8%) were discovered out of 71 biopsies. HPV-DNA tests were performed on the residual of 43 LBPs, 18 (41.9%) were positive for oncogenic HPV. Only 37 patients had follow-up biopsy and 15 (40.5%) were positive for oncogenic HPV, of which 40% (6/15) had a significant lesion. Of the 237 conventional AGC Paps, 18 lesions (15.3%) were discovered out of 118 biopsies.

CONCLUSIONS

Comparison of liquid-based and conventional Pap tests revealed a significant difference (33.8% vs. 15.3% respectively) (OR: 2.84, 95% CI: 1.4-5.73, p=0.004) in the detection of glandular and squamous lesions. HPV testing may prove beneficial to triage AGC patients with negative colposcopic findings and positive HPV results.

High-risk human papillomavirus DNA testing: a marker for atypical glandular cells

Cervical/endocervical cytology screening has decreased morbidity and mortality, and implementing adjunctive human papilloma virus (HPV) DNA testing for atypical squamous cells of undetermined significance has improved the specificity for detecting premalignant squamous lesions. Currently, there are no guidelines to perform HPV DNA testing on cervical/endocervical ThinPreps with atypical glandular cells (AGC). To assess the potential role of HPV DNA testing on AGC cases, Hybrid Capture 2 (Digene Corp.) testing was performed on 144 cervical/endocervical AGC specimens. One hundred three of 144 cases had follow-up; 60/103 (58.3%) were high-risk HPV negative and 43/103 (42.3%) were high-risk HPV positive. Of 43 HPV-positive patients, 37 had adenocarcinoma in situ (AIS), atypical squamous cells of undetermined significance (ASCUS), or cervical squamous intraepithelial neoplasia, while only one patient without high-risk HPV had a squamous intraepithelial neoplasia. Furthermore, most high-risk HPV positive AGC cases harbored high-grade squamous intraepithelial lesion (HSIL) rather than AIS. Our data support HPV DNA testing of all AGC specimens to detect cervical, especially squamous, neoplasia.

Risk factors of having high-grade cervical intraepithelial neoplasia/invasive carcinoma in women with atypical glandular cells of undetermined significance smears

The objective of this study was to find the risk factors of having high-grade cervical intraepithelial neoplasia/invasive carcinoma in women with atypical glandular cells of undetermined significance (AGUS) smears. A retrospective study of the women with AGUS smears during the 3-year period was performed to determine the correlation between the suspected variables and the histopathologic diagnoses. Among 44,071 smears performed, 119 (0.27%) smears were reported as AGUS. Colposcopies were performed in 102 (88.7%) cases, and high-grade cervical intraepithelial neoplasia/invasive carcinoma was found in 18 (17.6%) cases. Among the following variables, which included age, menopausal status, hormonal contraception, history of previous Pap smears, medical diseases, clinical symptoms, and subclassification of AGUS, both hormonal contraception and AGUS favor neoplasia were risk factors with an odds ratio of 5.4 and 5.0, respectively. Although clinical symptoms seemed to be a significant variable in univariate analysis, it appeared as a confounding factor in multivariate analysis.

A cytohistologic study of atypical glandular cells detected in cervical smears during cervical screening tests in Iran

Atypical glandular cells (AGC) often cause diagnostic uncertainty in cervicovaginal smears. To determine the incidence of significant pathologies associated with AGC on Papanicolaou test, AGC smears were correlated with subsequent biopsy diagnoses. A retrospective review of archives of our cytology files for cervicovaginal smears diagnosed as AGC from April 1998 to March 2001 was performed. In 9390 cervicovaginal smears, AGC were reported in 76 (0.81%) cases, with histologic follow-up in 42 patients (55.3%). Twenty-two patients (52.4%) had preneoplastic or neoplastic, squamous, or glandular lesions on histologic examination. Among them were cervical intraepithelial neoplasia, basal cell abnormality of undetermined significance, cervical adenocarcinoma, endometrial hyperplasia or adenocarcinoma, vaginal adenocarcinoma, endocervical glandular dysplasia, metastatic breast carcinoma, and simple nonvillous trophoblastic tissue. Therefore, presence of AGC in cervical smears may exhibit a spectrum of findings, ranging from benign/reactive changes to squamous or glandular premalignancy or malignancy. A majority of these lesions are squamous dysplasia, and a significant number of patients had glandular malignancy. The results of the current study underline the importance of follow-up for patients with the diagnosis of AGC. To our knowledge, this is the first report in Iran showing the significance of AGC diagnosis.

Atypical glandular cells: criteria to discriminate benign from neoplastic lesions and squamous from glandular neoplasia

OBJECTIVE

To evaluate the presence of some criteria in cervical smears with atypical glandular cells and their correlation with histological patterns to identify pre-neoplastic and neoplastic lesions.

METHODS

Seventy-three women referred with an atypical glandular cell smear, who had undergone conization or hysterectomy, were included in this study. Referral Pap smears were reviewed using the set of 27 cyto-morphological criteria that was correlated with the histological diagnosis.

RESULTS

Histological results showed intraepithelial or invasive neoplasia in 35 (48%) cases and benign lesions in 38 (52%) cases. After logistic regression and decision tree analysis an increased nuclear/cytoplasmic ratio and the presence of dyskeratotic cells were strongly associated with intraepithelial or invasive neoplasia and the differential cyto-morphological criteria for glandular lesions were decreased cytoplasm, irregular nuclear membranes and the presence of nucleoli.

CONCLUSION

The analysis of individual cyto-morphological criteria can better predict intraepithelial or invasive neoplasia and differentiate glandular from squamous lesions.

Dysplasia associated with atypical glandular cells on cervical cytology

OBJECTIVES

To estimate the rates of and identify risk factors for disease in women with atypical glandular cells of undetermined significance (AGUS).

METHODS

From 1998-2001, 477 Pap tests at Hartford Hospital were classified as AGUS and met the inclusion criteria of this study. Findings were evaluated for 2 years from the initial test. Disease was defined as histology results with a finding of high-grade squamous intraepithelial lesion or greater.

RESULTS

Disease was diagnosed in 9% of the women, including malignancy in 3%. Women with malignant-appearing AGUS Pap tests had a higher rate of disease (29%) than women with benign-appearing (5%, P < .01) and unspecified AGUS Pap tests (13%, P < .03). Malignancies were associated with all subclassifications of AGUS Pap tests. Women aged less than 35 years were more likely to have disease than women aged 35 years or older (P < .02). Most women aged younger than 35 years had a squamous abnormality, whereas women aged 35 years or older had a greater diversity of squamous and glandular lesions and accounted for all cases of endometrial cancer, adenocarcinoma in situ, and cervical adenocarcinoma. Women with persistent AGUS Pap tests had a 31% rate of disease. The rate of disease among women with AGUS Pap tests collected by liquid-based cytology was 11%, compared with 6% among samples collected by the conventional method.

CONCLUSION

These data suggest that women with atypical glandular cells are at substantial risk for dysplasia and malignancy. The rate of disease varies with the method of Pap test collection, age, presence of persistent AGUS Pap tests, and AGUS subclassification.

Detection of high-risk human papillomavirus (HPV) DNA by Hybrid Capture II in women referred due to atypical glandular cells in the primary screening

We assessed the detection of high-risk human papillomavirus DNA (HPV-DNA) in women examined by a second Pap smear due to atypical glandular cells (AGC) detected in their screening Pap smear. In 91 women included in the study, a second Pap smear was taken and HPV-DNA test was performed using Hybrid Capture II (HC II). The second Pap smear showed no abnormalities in 28 (31%) cases, ACG in 17 (19%) cases, and high-grade squamous intraepithelial lesions (HSIL) or worse in 24 (26%). HC II test was positive in 36% of the cases. Considering the second Pap smear diagnosis, HPV-DNA was detected in 87% of the women with HSIL, 100% of women with in situ adenocarcinoma, and only in 11% of the women with no abnormalities. The use of the second Pap smear combined with HPV-DNA may improve the management of women with AGC in the primary screening.

Human papillomavirus DNA detection and histological findings in women referred for atypical glandular cells or adenocarcinoma in situ in their Pap smears

OBJECTIVE

To evaluate the association between high-risk human papillomavirus (HPV) DNA detection and histological diagnosis in women referred for atypical glandular cells (AGC) or adenocarcinoma in situ (AIS) at Pap smear.

METHODS

In this cross-sectional study, 146 women referred for AGC (124), AGC with high-grade squamous intraepithelial lesion (HSIL) (15), or AIS (7) were tested for HPV DNA using Hybrid Capture II (HC II). All women underwent colposcopic examination, and cervical biopsy was performed for 95 patients. Fifty-one women referred due to AGC with normal colposcopy and normal second Pap smear were scheduled for control visits every 4 months.

RESULTS

The overall prevalence of HPV DNA was 38%. HPV DNA was detected in 93% of the women with HSIL associated with AGC and in 71% of women with AIS Pap smear, being significantly higher when compared with the prevalence (29%) in women with AGC alone. Forty-five women (30.8%) had clinically significant histological lesions (CIN 2 or worse). High-risk HPV DNA was detected in only 16% of the women without significant abnormalities in biopsy, in contrast to 96% of those who had CIN 2 or CIN 3 and 75% of women with AIS. Eighty-five percent of women with invasive cervical carcinoma (squamous or adenocarcinoma) tested positive for HPV DNA. HPV DNA detection was significantly associated with histological diagnosis of CIN 2 or worse, with an odds ratio (OR) = 51.8 (95% CI 14.3-199.9).

CONCLUSION

HPV DNA detection was strongly associated with the severity of cervical lesion (CIN 2 or worse) in women referred for AGC or AIS in their Pap smear. These data implicate the use of HPV testing in triage of women with AGC Pap smears.

Atypical glandular cells in conventional cervical smears: incidence and follow-up

BACKGROUND

Atypical glandular cells on cervical smears are often associated with clinically significant uterine lesions. The frequency and accuracy of AGC-NOS (i.e. atypical glandular cells, not otherwise specified) diagnoses, regardless of the gland cell type or the degree of suspicion, and their outcome were investigated.

METHODS

From January 1, 1990 to December 31, 1999 a total of 261 patients had an AGC-NOS diagnosis made by conventional cervical Papanicolaou smear interpretation representing 0.05% of all Pap-smears analyzed at the national level. 191 (73.2%) patients had a subsequent histological examination, 8 samples were not representative by origin and were excluded.

RESULTS

Out of 183 AGC-NOS diagnosed, 56.3% (103/183) were associated with tissue-proven precancerous and/or cancerous lesions, 44% being of endocervical and 56% of endometrial origin. 75% of all AGC-patients were asymptomatic. 66.7% (6/9) of the patients with subsequent invasive endocervical adenocarcinoma (AC) and 56% (28/50) of those patients with invasive endometrial AC were without clinical symptoms. 3 patients out of 9 with an invasive endocervical AC were 35 years of age or less. 10.1% and 12.3% of all 'new' tissue-proven invasive endocervical or endometrial AC respectively recorded by the national Morphologic Tumour Registry (MTR) were first identified by a cytological AGC-NOS diagnosis.

CONCLUSION

Our findings emphasize the importance of the cytological AGC-category even in the absence of a precise origin or cell type specification. 56% of the AGC-diagnoses being associated with significant cancerous or precancerous conditions, a complete and careful evaluation is required.

Significance of MiB-1 staining in smears with atypical glandular cells

MiB-1 immunostaining may facilitate recognition of developing adenocarcinoma in cervical smear screening. In a retrospective analysis of prospectively collected data of 170 patients with atypical endocervical glandular cells and with repeat smears, archival Papanicolaou-stained smears were restained for MiB-1 and classified for the presence of preneoplastic changes of MiB-1 positive epithelial fragments. The results of classification based on MiB-1 positive epithelial fragments corresponded "roughly" with cytomorphological diagnoses. Of the 38 patients in which the primary smear was found to be MiB-1-positive, 12 of these persisted in the repeat smear. Thirty-eight of the 132 repeat smears of patients originally negative for MiB-1 pathology were positive. Of the total 50 MiB-1 positive repeat smears, four showed adenocarcinoma in situ on cytomorphological grounds. MiB-1 staining enhances detection of (pre)neoplastic changes. This approach does not destroy the morphology of the original smear and can be applied to routine material.

Atypical glandular cells?an update

The diagnostic category of atypical glandular cells (AGC) in the Bethesda system for the reporting of cervicovaginal cytology has undergone significant modification since its inception in 1988. More than a decade later, this category remains a diagnostic challenge to both clinicians and cytopathologists because of the lack of uniform cytologic criteria, the lack of interobserver agreement in the diagnosis, and the lack of standardized patient management guidelines. This article reviews the current classification of AGC in the Bethesda system, the cytomorphologic features and differential diagnosis, the clinical significance of a diagnosis of AGC, and the clinical management of patients with AGC. This article provides a comprehensive clinicopathologic review of the category of AGC.

Atypical glandular cells

The 2001 Bethesda System has radically altered the classification of glandular abnormalities. The recognition of the cytologic features of atypical glandular cells on cervicovaginal smears is important because a significant number of patients will be found to have an underlying cancerous or dysplastic lesion of the exocervix, endocervix, or endometrium. The differential diagnosis of AGC on cytology is diverse and accurate classification is necessary because the most appropriate form of follow-up depends on the specific subcategorization of the atypical glandular cells. Because the level of interobserver agreement in the diagnosis of AGC is poor, effective communication between cytopathologists and clinicians is essential to accurately triage these patients. This article should help the cytology practitioner by providing a comprehensive review of the approach to the interpretation, clinical significance, histopathologic correlation, and management of patients who have atypical glandular cells on gynecologic cytology specimens.

Atypical glandular cells: new Bethesda Terminology and Management Guidelines

Although Pap tests have enabled early detection of premalignant lesions, the introduction of new collecting devices has significantly improved the detection of lesions hidden in the endocervical canal, such as adenocarcinoma in situ (AIS). The term "atypical glandular cells of undetermined significance" (AGUS) was introduced at the 1988 Bethesda Conference and defined as morphologic changes in glandular cells beyond those that are suggestive of the benign reactive process, but insufficient for the diagnosis of adenocarcinoma in situ (AIS). In the new 2001 Bethesda System, the term has been eliminated and replaced with the term "atypical glandular cells" (AGC), with the following subclassifications: not otherwise specified (NOS), favor neoplasia, endocervical AIS, and adenocarcinoma. The risks of premalignant or malignant disease associated with the AGC favor neoplasia category are substantially higher than in the AGC NOS category (96% vs. 9-41%, respectively). Patients diagnosed with AGC NOS or AGC favor neoplasia will require colposcopy, endocervical sampling, and, for patients over 35 years of age, endometrial biopsy. If all of these tests are negative, the Pap test should be repeated in 4-6 month intervals until 4 consecutive normal tests are obtained. Positive results in one of the tests will require management according to ASCCP guidelines. The AGC favor neoplasia diagnosis also requires cervical conization and/or other testing, as the incidence of premalignant or malignant lesions in patients with this diagnosis is high. The role of HPV testing in this setting is unknown at this time.

Cytology suggestive of glandular neoplasia: outcomes and suggested management

Eighty-three cases having a cervical smear result showing abnormal glandular cells were identified and matched up with the diagnostic histology result. Thirty-four (41.0%) were associated with malignancy and 26 (31.3%) with a cervical intraepithelial lesion without invasion. Thirty-eight (45.8%) had conditions of the cervix as follows: 12 cases had invasive disease of the cervix; nine (10.8%) adenocarcinoma of cervix and three (3.6%) squamous carcinoma of cervix. Nineteen (22.9%) had cervical intraepithelial neoplasia (CIN/SIL) alone and seven (8.4%) had cervical glandular intraepithelial neoplasia (CGIN) +/- CIN. There were 16 (19.3%) cases with malignancies of the uterine corpus and six (7.2%) had a malignancy arising from another primary site. Twenty-three (27.7%) had no malignant or pre-malignant condition. The risk of malignancy was related to age and ranged from 18.2% in those under 35 years to 67.9% in those 55 years and over. A protocol for the management of these cases is described.

Predictive value of diagnoses of endocervical glandular abnormalities in cervical smears

AIMS

To determine the positive predictive value (PPV) of cervical smear diagnoses of 'definite' and 'possible' endocervical adenocarcinoma in situ or invasive adenocarcinoma, and whether diagnostic accuracy can be improved.

METHODS

The study examined cervical smears reported as definite or possible high-grade glandular abnormality between 1992 and 1998. PPV was calculated by comparing smear diagnoses with the subsequent histopathology report. All available smears were reviewed without knowledge of follow-up results, and were reclassified by consensus.

RESULTS

Thirty-two smears were diagnosed as high-grade glandular lesions, with adequate biopsy follow-up in 31 cases (96.9%). A high-grade epithelial abnormality (HGEA) was detected in 29 cases (PPV, 93.5%), with a high-grade glandular lesion in 24 (PPV, 77.4%). Very few smears were reclassified on review. Seventy-three smears were initially diagnosed in the 'inconclusive' glandular or indeterminate cell-type category. There was adequate biopsy follow up for 54 cases (74.0%). On follow-up, 31 cases had a HGEA (PPV, 57.4%), with 14 cases having a high-grade glandular abnormality (PPV, 25.9%). In the review of 'inconclusive' smears, 12 were reclassified as squamous abnormalities and none of these had a glandular lesion on biopsy. Eight were reclassified as negative; seven contained endometrial stroma and the glandular cells in question were considered to be of lower uterine segment (LUS) origin. No significant lesion was present on follow-up of these cases.

CONCLUSIONS

For clinicians using our laboratory, large loop excision of the transformation zone (LLETZ) or cone biopsy should follow a 'definite' cytological diagnosis of a high-grade endocervical glandular lesion. However, cone biopsy may not be the appropriate initial management in the 'possible' high-grade glandular group because of a significantly lower predictive value of the diagnosis. The slide review highlighted the importance of (1) caution in classifying sheets of abnormal cells as glandular, and (2) endometrial stroma as a marker of LUS material.

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.

Atypical glandular cells of undetermined significance (AGUS): clinical considerations and cytohistologic correlation

The diagnoses of atypical glandular cells of undetermined significance (AGUS) made upon evaluation of cervical/vaginal (Pap) smears is examined to ascertain salient clinical and cytologic features that may lead to better characterization of the true nature of these lesions. Prior history of squamous dysplasia, age of the patient, and the occurrence of abnormal microbiopsy tissue fragments are investigated to determine their value in the proper evaluation of AGUS specimens. Of the 86,234 Pap smears submitted to our laboratory during a period of 2 yr, 187 (0.2%) were diagnosed as AGUS. Available follow-up in 128 (69%) cases revealed 54 (42%) significant tissue proven abnormalities, the majority (55%, 30 patients) of which were diagnosed as squamous intraepithelial lesions (SIL). Squamous dysplasia is significantly more common in women younger than 40 (15/18, 83%) and in patients with prior history of SIL (29/30, 97%). In addition, all nine patients diagnosed with endometrial lesions on subsequent histology were older than 40. Age, however, was not a discriminating factor in women proven to have endocervical glandular lesions. Additionally, certain tissue fragment cytomorphologic features were significantly more often observed on follow-up in specific histologic diagnostic categories. The Pap smears of patients diagnosed with SIL were noted to contain tissue fragments composed of both dysplastic squamous and benign glandular cells in 29 of 30 (97%). The presence of two distinct populations of glandular tissue fragments (typical and atypical) was found in the Pap smears of all nine women with endometrial abnormalities and in the smears of most women subsequently diagnosed with endocervical glandular lesions (87%, 13/15). These observations suggest that a more specific and clinically useful Pap smear interpretation other than AGUS is often possible by consideration of the patient's age and prior history along with the correct identification of the type of atypical cells observed in abnormal tissue fragments.

Clinical implications of atypical glandular cells of undetermined significance, favor endometrial origin

BACKGROUND

The Bethesda System recommends qualifying atypical glandular cells with regard to their possible origin: endocervical versus endometrial. This study was undertaken to determine the clinical significance of atypical glandular cells of undetermined significance that favor an endometrial origin (AGUS-EM).

METHODS

A computer search identified 62 cervicovaginal smears (5.25% of all smears classified as AGUS) with a diagnosis of AGUS-EM in the files of Shared Cytopathology Laboratory of New York University Medical Center/Bellevue Hospital Medical Center between January 1995 and December 1999. The patients ranged in age from 29 years to 88 years (mean age, 53 years). Thirty-four patients were postmenopausal (55%), and 5 patients were on hormonal replacement therapy. Follow-up was available for 56 patients (90%); 45 patients (73%) underwent biopsy, and 11 patients (17%) had repeat cervicovaginal smears. Six patients were lost to follow-up.

RESULTS

Among patients who underwent biopsy, 14 patients (31%) had a clinically significant uterine lesions, including 6 (13%) endometrial adenocarcinomas, 5 (11%) endometrial hyperplasias, and 3 (7%) squamous lesions (2 high-grade squamous intraepithelial lesions and 1 squamous cell carcinoma). Ten of 11 patients with significant endometrial pathology findings were postmenopausal. The remaining 31 patients had benign pathology results, which included chronic cervicitis, endometritis, endometrial polyps, microglandular hyperplasia, and tubal metaplasia. Among the patients with repeat cervicovaginal smears, one patient had atypical squamous cells of undetermined significance; the remaining patients were within normal limits.

CONCLUSIONS

Approximately one-third of women with a diagnosis of AGUS-EM had a significant uterine lesion on subsequent biopsy; the majority of these lesions were endometrial in origin. Patients with a diagnosis of AGUS-EM on cervicovaginal smears should be followed closely, and endometrial curettage or biopsy should be included in their initial work-up.

Can glandular lesions be diagnosed in pap smear cytology?

Many reports have been published on the accuracy of the cervical vaginal smear for squamous lesions, and the literature contains fewer reports on the accuracy of the cervical vaginal smear for glandular lesions. The sensitivity of glandular lesion diagnosis depends on the subtype of lesion. The diagnostic sensitivity is highest for invasive endocervical adenocarcinoma and lowest for endometrial adenocarcinoma. The ability of some of the Bethesda system categories for glandular lesions to describe what they purport to describe is questionable. The Bethesda system categories of adenocarcinoma accurately classify adenocarcinomas. The Bethesda System category of atypical glandular cells of undetermined significance (AGUS) is a misnomer. Although many cases of adenocarcinoma in-situ are placed in this category, follow-up of patients with AGUS show that the majority of patients with clinically significant lesions have squamous dysplasias. Other categories of AGUS, such as AGUS favor endometrial origin, are more appropriately named and encompass endometrial lesions which are either neoplastic or non-neoplastic.

Atypical glandular cells of undetermined significance Pap smears: appropriate evaluation and management

This review focuses on atypical glandular cells of undetermined significance Pap smears, with attention given to the classifications of atypical glandular cells of undetermined significance, the clinical and histopathologic correlation, and recent advances in triage strategies for this entity. The management of atypical glandular cells of undetermined significance Pap smears will emphasize the significance of this finding in terms of diagnosing dysplasia and carcinoma of the lower female genital tract.