Diagnosis Of Atypical Squamous Cells Research Articles

Understanding cytomorphologic changes in Pap tests of transgender men on testosterone therapy

Abstract Introduction/Objective Pap test findings in transgender men on testosterone therapy can often lead to misdiagnosis of dysplasia, especially in the setting of a positive HPV test. We reviewed relevant literature to analyze the cytomorphological nuances and applicable correlations to subsequent pathology in Pap tests of transgender men on testosterone therapy. Methods/Case Report We searched peer-reviewed journals on PubMed, synthesizing five articles published from 2018-2022 that specifically address cytomorphological findings on cervical Pap tests and biopsy results in transgender men on testosterone therapy. Results (if a Case Study enter NA) Various cytological changes, such as small parabasal-type cells and transitional cell metaplasia (TCM) can be mistaken for dysplasia in transgender men. In fact, these changes are representative of atrophy due to testosterone, as such findings have been observed in patients undergoing tamoxifen therapy. Small parabasal-type cells are described as clusters or sheets with intermittent nuclear enlargement and hyperchromatic nuclei, whereas TCM comprises flat sheets of cells with oval to spindle-shaped nuclei, powdery chromatin, and prominent nuclear grooves. Relevant clinical history can often help clarify cytologic diagnoses, as Pap tests that show atrophic changes can be misinterpreted as being abnormal. In several cases described in the literature, original diagnoses of atypical squamous cells of undetermined significance (ASCUS) were re-interpreted as atrophic changes after eliciting a history relevant for testosterone therapy. Small parabasal-type cells found on cytology have correlated with sections of the ectocervix that have groups of small hyperchromatic cells attached to the surface of atrophic cervical epithelium or areas of TCM. These cells may be mistaken for endometrial cells, especially in patients over 45 years old. Distinguishing atrophic changes from dysplasia on surgical pathology may modify cytologic diagnoses. Conclusion Transgender men on testosterone therapy often retain their cervix, necessitating ongoing cervical cancer screening. However, Pap test results from these individuals often exhibit atrophic changes through the presence of small parabasal-type cells and TCM. Differentiating between atrophy and dysplasia can pose a diagnostic challenge, especially in the setting of positive HPV testing or inflammation. Continued analyses into these cytomorphological nuances will assist providers in refining their diagnostic approaches and providing personalized care to transgender men.

Liquid-based Anal Cytology as a Screening Tool for Prevention of Anal Cancer in at-risk Populations: A Single-Center Retrospective Analysis on 111 Patients

Abstract Objective Squamous cell carcinoma of the anus (SCCA) is associated with human papillomavirus (HPV) infection in almost 90% of the cases. Its incidence is alarmingly high among men who have sex with men (MSM) and continues to increase at an average rate of 2% per year. The objective of the present study is to evaluate the usefulness and performance of liquid-based anal cytology as a screening tool for prevention and early detection of SCCA in a cohort of at-risk men. Method We conducted a retrospective study including 111 MSM, aged between 22 and 62 years old, who underwent anal cytological screening with a liquid-based Pap test at our sexually transmitted diseases (STDs) clinic from January 2015 to March 2017. Results Out of 111 anal smears, 57 (51,4%) resulted negative, 42 (37,8%) abnormal, and 12 (10,8%) unsatisfactory for the cytological evaluation. Only patients with an abnormal cytology underwent anoscopy and subsequent biopsy. The histological results were as follows: negative for squamous intraepithelial lesion (SIL) in 5 cases, low-grade SIL (L-SIL) in 21, high-grade SIL (H-SIL) in 5, SCCA in 1. Five patients had a normal anoscopy and biopsy was not taken. Conclusion Liquid-based cytology, reducing the “darkening factors” typical for the conventional smears, has a higher positive predictive value than the traditional technique. Moreover, a cytological diagnosis of atypical squamous cells of undetermined significance (ASC-US) or L-SIL may hide a severe dysplasia or even a carcinoma. Thus, all patients with an abnormal anal cytology at any grade should be considered for anoscopy.

Loss to follow-up of women with initial cervical cytology of ASC-US/LSIL in Tocantins, Brazil

Objective: The study aims to characterize loss to follow-up of women with initial cytological diagnosis of atypical squamous cells of undetermined significance, possibly non-neoplastic (ASC-US), or low-grade squamous intraepithelial lesion (LSIL), in Tocantins State, Brazil, from 2011 to 2013. Study Design: Cervical cytology data from the Information System on Uterine Cervical Cancer (SISCOLO) was used to identify women with initial diagnosis of ASC-US or LSIL in 2011. Nominal database record linkage was used to identify women with previous altered Pap smear results (who were excluded) and those who returned (versus failed to return) by the year 2013. Results: Record linkage identified 1,174 women with diagnoses of ASC-US (65.9%) or LSIL (34.1%) and without previous altered tests. According to the data, 55.9% and 53.5%, respectively, failed to undergo follow-up tests in the subsequent years. Conclusion: Failure to return for repeat cervical cytology suggests a missed opportunity for diagnosis and treatment of women with precursor lesions or cervical cancer not detected in the initial cytology, thus compromising the effectiveness of cervical cancer control in the State of Tocantins.

Characteristics of Cervical Precancerous Lesions at a Tertiary Hospital in Bali, Indonesia

Background: Cervical cancer is one of the biggest women’s health issues in developing countries including Indonesia. This study is aimed to describe the characteristics of cervical precancerous lesions at a tertiary hospital in Bali, Indonesia.Methods: This is a descriptive study using data from the medical records of patients with precancerous cervical lesions who attended the Gynecologic Oncology Outpatient Clinic Sanglah Hospital Denpasar, Bali, Indonesia, from January to December 2017. Results: There were 276 cases (2.88%) of the cervical precancerous lesion during the study period. The majority of cases were diagnosed within the age group of 36-45 years (37.7%), had low education levels (42.7%), obese (53.5%), multiparous (73.9%), had first sexual intercourse at the age of 16-20 years (41.3%), had used IUD as a contraceptive method (41.4%), and had a cytologic diagnosis of atypical squamous cells of undetermined significance (ASC-US) that preceded the histologic diagnosis (43.2%). The most common histologic diagnosis was CIN I (43.1%) and the most common treatment was cryotherapy (56.2%).Conclusions: The majority of cervical precancerous lesion cases were diagnosed among women who were between her third and fourth decade of life, had low education level, were obese, multiparous, had a sexual debut at a younger age, and were IUD users. The majority of cases were low-grade lesions.

Interpreting a Diagnosis of Atypical Squamous Cells of Undetermined Significance in Cervical Cytology and its Association with Human Papillomavirus: A retrospective analysis of 180 cases in Kuwait.

ObjectivesAtypical squamous cells of undetermined significance (ASC-US) represent a diagnostic challenge during cervical cytology. This study aimed to review and identify high-risk human papillomavirus (HR-HPV) genotypes among previously diagnosed ASC-US cases in Kuwait.MethodsThis retrospective study analysed 180 cases diagnosed as ASC-US between June 2017 and May 2018 at the Mubarak Al-Kabeer Hospital, Kuwait. Cervical specimens were assayed to determine the presence of HR-HPV DNA; subsequently, positive cases underwent genotyping and were categorised into three groups (HPV 16, HPV 18/45 and other HR-HPV types).ResultsIn total, ASC-US was confirmed in only 105 cases (58.3%), with the remaining cases reclassified as negative for intraepithelial lesions or malignancy (NILM; 32.2%) and epithelial cell abnormalities (ECA; 9.4%). Of these, HR-HPV DNA was present in 20 ASC-US (19%), one NILM (1.7%) and six ECA (35.3%) cases. There were 62 Kuwaiti and 43 non-Kuwaiti women with confirmed ASC-US; of these, three (4.8%), six (9.7%) and four (6.5%) Kuwaitis and one (2.3%), one (2.3%) and five (11.6%) non-Kuwaitis had HPV 16, both HPV 16 and 18/45 and other HR-HPV genotypes, respectively. Of those with HR-HPV DNA, the NILM case had the HPV 18/45 genotype, while the six ECA cases had the HPV 16 (n = 1), both HPV 16 and 18/45 (n = 1) and other HR-HPV (n = 4) genotypes.ConclusionOverall, HR-HPV DNA was present in 19% of ASC-US cases compared to 1.7% of NILM cases initially misdiagnosed as ASC-US. Re-review of cervical cytology diagnoses may reduce unnecessary costs associated with HR-HPV genotyping.

Abstract 1123: Simultaneous p16/ki-67 expression in detection of high-grade squamous intraepithelial lesions, in women with ASC in cervical smears

Abstract Background Immunocytochemical staining for overexpression of the cell-cycle regulatory protein p16INK4a has been shown to be an efficient approach to triage to colposcopy women with cervical smears categorized as Atypical Squamous Cells (ASC). Overexpression of p16 is associated with the transforming activity of the HR-HPV-E7 oncoprotein in cervical dysplasia. Ki-67 is a marker of cell proliferation of dysplastic epithelium. The efficiency of p16 and Ki-67 separately has been widely described. In high-grade squamous intraepithelial lesion (H-SIL) and cancer they can be co-expressed and the identification of cells with double staining reactivity (p16/Ki-67) can be used as an indicator of H-SIL. We aim to evaluate the diagnostic performance of double p16/Ki-67 staining in the detection of underlying H-SIL in cytological smears of women referred to colposcopy due to an ASC cervical smear result. Design Prospective diagnostic test study. It took 18 months to complete the representative number of cases considering the prevalence of ASC in the colposcopy consultation. Samples were included from patients referred to colposcopy with a cytological diagnosis of ASC. Liquid based cytology was taken and processed to obtain a blank cytological preparation. The p16/Ki-67 staining was performed using CINtec Plus™. The immunoreactivity for both markers evidenced by one or more cervical epithelial cells with brown cytoplasmic immunostaining for p16, and nuclear red for Ki-67, was evaluated by two pathologists blind to colposcopy or biopsy results. Biopsies and/or endocervical curettage were obtained when the colposcopist considered necessary and they were considered as gold standard. In cases where there was no visible lesion and no biopsy was taken, colposcopy was considered gold standard and it was classified as: satisfactory/unsatisfactory, negative/normal or positive/abnormal. A high-grade biopsy lesion (≥ CIN2) with H&E was considered as a final diagnosis. Results There were 120 cases included of ASC (114 ASCUS and 6 ASC-H), from women between 18 and 82 years (mean=38.6). 90 (75.0%) cases had histological study: 62 (68.9%) biopsies and 28 (31.1%) endocervical curettages, of which 17 (14.28%) cases had ≥CIN2, and none were cases of invasive cancer. p16/Ki-67 staining was positive in 21 (17.5%) cases, (64.7% sensitivity for ≥CIN2). All the ASC-H cases (3, 100%), and 57.1% of ASCUS cases with ≥CIN2 as final diagnosis were positive to p16/Ki-67. The specificity of p16/Ki-67 dual staining was greater than 90%. Conclusions There was a p16/Ki-67 specificity that exceeded the values ​​published in other studies on this double staining, but, the positivity and sensitivity estimates were lower than reported previously. The variability of p16/Ki-67 staining in HSILs would reflect the heterogeneity of these lesions. Citation Format: Lia Barrios, Luis Alvis, Ines Benedetti. Simultaneous p16/ki-67 expression in detection of high-grade squamous intraepithelial lesions, in women with ASC in cervical smears [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1123.

The Efficiency of Type-Specific High-Risk Human Papillomavirus Models in the Triage of Women with Atypical Squamous Cells of Undetermined Significance.

PurposeTo evaluate the performance of different high-risk human papillomavirus (HR-HPV) genotype models in triaging women with cytological diagnosis of atypical squamous cells of undetermined significance (ASCUS).Patients and MethodsA total of 36,679 Chinese women who underwent cytology and HR-HPV genotyping assessments during cervical cancer screening were enrolled in this study. Women with cytology-proven ASCUS were referred for further screening by colposcopy and biopsy. The study endpoint was histological detection of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) at any of the follow-up visits. The sensitivity, specificity, positive predictive values (PPVs), negative predictive values (NPVs), positive likelihood ratio (PLR) and negative likelihood ratio (NLR) of different HR-HPV genotype combination models were estimated.ResultsIn all, 1675 (4.9%) women were identified as having ASCUS, 1454 women underwent colposcopy and biopsy, and 6.0% (87/1454) women were identified as having CIN2+ lesions. Among those with ASCUS who were identified as having CIN2+, the HR-HPV infection rate was 97.7%, and the prevalence rates of HPV-16, −18, −31, −33, −35, −39, −45, −51, −52, −56, −58, −59, −66 and −68 were 48.3%, 8.0%, 6.9%, 4.6%, 1.1%, 2.3%, 3.4%, 3.4%, 26.4%, 1.1%, 17.2%, 2.3%, 0.0% and 0.0%, respectively. Compared to other HR-HPV-type combination models, the HPV16/18/31/33/52/58 model achieved a higher sensitivity [93.1 (87.8–98.4)], specificity [73.0 (70.7–75.4)], PPV [18.0 (14.5–21.5)], NPV [99.4 (98.9–99.9)], PLR [3.7 (3.1–3.8)] and NLR [0.06 (0.03–0.18)] for the triage of ASCUS patients, but the colposcopy referral rate (30.9%) was significantly lower than that of the recommended HR-HPV model (44.0%).ConclusionThis study confirms that the specific HR-HPV genotype HPV16/18/31/33/52/58 is an alternative strategy for ASCUS triage and can effectively reduce the high burden of colposcopy referrals in China.

Sensitivity and specificity values of high-risk HPV DNA, p16/ki-67 and HPV mRNA in young women with atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesion (LSIL).

The aim of the study was to evaluate the sensitivity and specificity values of high-risk HPV DNA test, p16/ki-67, and HPV mRNA in histologically high-grade cervical intraepithelial lesions (CIN2-CIN3) in women aged 21-24 years with diagnosis of atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesion (LSIL) at pap smear. 342 patients between 21-24 years old, attending spontaneously our clinics, 118 with ASCUS and 224 with LSIL, were enrolled in the study. All patients underwent colposcopy and biopsies were performed in the areas with major changes. All patients were tested at the same time for p16/ki-67, high-risk HPV DNA and HPV mRNA. Nineteen out of 118 women with ASCUS showed a high-grade cervical intraepithelial lesion, 11 out of 118 (9.32%) CIN2, and 8 out of 118 (6.78%) CIN3. The sensitivity of high-risk HPV DNA was 99.9%, and the specificity 23.2%; p16/ki-67 pointed out a sensitivity of 90.9%, and a specificity of 81.8%; HPV mRNA showed a sensitivity of 81.8%, and specificity of 87.9% in CIN2 lesions. In CIN3 lesions, the sensitivity of high-risk HPV DNA was 99.9%, while the specificity was 19.1%; p16/ki-67 showed a sensitivity of 99.9%, and a specificity of 73.7%; HPV mRNA relived a sensitivity of 87.5%, and a specificity of 80.8%. In women with LSIL, a total of 42/224 (18.75%) of CIN2 were found at the histopathological examination, while 17/224 (7.59%) women presented a CIN3. No case of invasive cancer was identified. High-risk HPV DNA was positive in 190/224 (84.8%), p16/ki-67 in 119/224 (53.1%), and HPV mRNA in 104/224 (46.4%). In women with CIN2, the sensitivity of high-risk HPV DNA was of 92.8%, and the specificity 17.5%, the sensitivity of p16/ki-67 was 95.2%, and specificity 61.8%. HPV mRNA showed a sensitivity of 88.8% and a specificity of 87.8%. In women with CIN3, the sensitivity of high-risk HPV DNA was 88.2%, and the specificity 29.7%; p16/ki-67 pointed out a sensitivity of 94.1%, and a specificity of 49%; HPV mRNA showed a sensitivity of 88.2% and a specificity of 80.6. Taking into account the high rate of spontaneous regression of high-grade lesions in young women, these tests, in particular, the HPV mRNA test, used as a triage test for ASCUS or LSIL, can modify follow-up triage strategy. In fact, this biomarker, due to its high specificity, could lead to a cytology repetition instead of an immediate colposcopy, avoiding over diagnosis and potential overtreatment in this category of women.

Performance Indicators for Colposcopy in Ontario.

This study sought to evaluate the delivery of colposcopy assessments and treatments in Ontario from 2009 to 2017 according to specific performance measures, derived from guidelines on colposcopy use. This population-based descriptive analysis included screen-eligible women ages 21 to 69 in Ontario who underwent cervical screening between 2009 and 2017. Performance measures that describe the quality of colposcopy services in the province were calculated. Five performance measures were used to assess the use of colposcopy in Ontario from 2009 to 2017. From 2013 to 2017, the percentage of women seen for colposcopy after a first diagnosis of atypical squamous cells of undetermined significance (ASCUS), without evidence of repeat cytology, remained stable, ranging from 5.9% to 6.3%. The median wait time to colposcopy for atypical glandular cells (AGC), atypical squamous cells (ASC-H), cannot rule out high-grade squamous intraepithelial lesions, and high-grade squamous intraepithelial lesions (HSIL), remained relatively stable from 2013 to 2017. In addition, the percentage of women with high-grade Pap test results who were seen in colposcopy within 6 months increased from 74.7% to 83.5%. The percentage of women who were not seen in follow-up within 12 months after treatment for cervical dysplasia remained stable, as did the percentage of women who discontinued colposcopy after three normal Pap test results following treatment for cervical dysplasia. This study developed five performance indicators and used them to assess the delivery of colposcopic services in Ontario from 2009 to 2017. Performance indicators have previously been used effectively in the field of colorectal cancer screening to identify strengths and weaknesses in the delivery of healthcare services. This had never previously been done in colposcopy.

Prevalence of epithelial abnormalities and high-risk human papilloma virus in cervicovaginal Pap smears of population subgroups as a guide toward evidence-based best practice.

The 2012 American Society for Colposcopy and Cervical Pathology Consensus Guidelines provide information for managing abnormal cervical cancer screening tests and cancer precursors. According to these guidelines for Pap smear diagnosis of Atypical squamous cells of undetermined significance, reflex high risk (HR) human papilloma virus (HPV) genotyping is required among women 21 years of age or older. Whereas, in women of 30 to 65 years of age, HR-HPV can be ordered by the clinicians as part of co-testing with any diagnosis and every 5 years with a negative Cervico-Vaginal Pap test (CVPT). A retrospective review of the CoPath database of the Pathology Department at the University of Florida, College of Medicine Jacksonville, FL, was performed to identify North Florida (NF) women who underwent CVPT and HR-HPV testing between 2006 and 2014. The women were stratified by race and age, respectively. The study included 19,933 CVPTs. Significant differences in the outcomes' distributions were found among age and race groups, respectively. Highest prevalence of HPV positivity was found in African American women, and in 14- to 20-year-old women, respectively. Twenty- to 30-year-old women had the highest percentage (59%) of epithelial abnormality. The most common HR-HPV genotypic distribution was other HR-HPV. This study underscores the importance of using both HR-HPV and CVPT for screening for cervical cancer, and confirms the need for special focus on managing high-risk populations subgroups, such as African American women, and women of ages 14 to 20 years especially in high-risk populations.

Performance of rapid prescreening and 100% rapid review as internal quality control methods for cervical cytopathology.

An objective of quality control for cervical cytopathology is reducing high rates of false-negative results of laboratory tests. Therefore, methods to review smears such as rapid prescreening and 100% rapid review, which have shown better performance detecting false-negative results, have been widely used. The performance of rapid prescreening and the performance of 100% rapid review as internal quality control methods for cervical cytology examinations were evaluated. For 24 months, 9318 conventional cervical cytology smears underwent rapid prescreening and routine screening. The 100% rapid review method was performed for 8244 smears classified as negative during routine screening. Any discordant results underwent detailed review to define the final diagnosis. This was considered the gold standard for evaluating the performance of rapid prescreening and 100% rapid review. Routine screening showed increases of 13.3% and 11.5% in the detection of abnormal smears with rapid prescreening and 100% rapid review, respectively. The relative percentage variation showed a 38.1% increase in the diagnosis of atypical squamous cells of undetermined significance with routine screening and rapid prescreening and a 12.5% increase in the diagnosis of atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion with both rapid prescreening and 100% rapid review. Sensitivity rates of rapid prescreening and routine screening were 48.2% and 83.2%, respectively. Sensitivity rates of rapid prescreening and 100% rapid review were 65.7% and 57.8%, respectively, for detecting false-negative results. Inclusion of rapid prescreening and/or 100% rapid review improved the diagnostic sensitivity of the cervical cytology examination and reduced false-negative results of routine screening and can provide good quality control.

Diagnostic value of p16/mcm2 dual staining in cervical intraepithelial neoplasia and its association with high-risk HPV infection

Objective: To study the expression of p16/mcm2 immunocytochemical dual staining in cervical lesions and its association with high-risk HPV infection, and discuss its clinical value in cervical cancer screening. Methods: From May to December 2015, a total of 1 127 women receiving cervical cancer screening, high-risk HPV (HR-HPV) test and liquid-based cytology test were included in the study. p16/mcm2 immunocytochemical dual staining was performed on residual cytology specimens and the results were compared with histopathology results. Results: p16/mcm2 had a higher expression risk in HPV16/18 group and other HR-HPV group compared with HPV negative group, with OR of 15.95 (95%CI: 9.59-26.51) and 10.53 (95%CI: 7.41-14.98), respectively. The positive rate of p16/mcm2 increased with cervical intraepithelial neoplasia (CIN) severity, and was higher in both CIN2 group and CIN3 group than in benign lesion group (P<0.05). The overall sensitivity of p16/mcm2 to detect CIN2+and CIN3+lesions were 86.1% and 92.0%, respectively, and the overall specificity were 46.1% and 44.4%, respectively. In group with cytologic diagnoses of atypical squamous cells (ASC) and low-grade squamous intraepithelial lesion (LSIL), the sensitivity to detect CIN2+and CIN3+lesions were 85.7% and 87.5%, respectively, and the specificity were 45.5% and 44.1%, respectively. Conclusions: p16/mcm2 dual staining has higher sensitivity than cytology test and better specificity than HPV test. It can identify high-grade cervical lesions and guide the classification of CIN. p16/mcm2 might be used as an innovative biomarker for cervical cancer screening.

Follow-up of women with cervical cytological abnormalities showing atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion: a nationwide cohort study

Atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion in abnormal cervical cytology among young women in cervical cancer screening is an increasing health burden, and comparative effectiveness studies of different management options for such diagnoses are needed. The objective of the study was to compare the incidence of invasive cervical cancer, following different management options pursued after an atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesion index smear. In this nationwide cohort study, we included all women aged 22-50 years and resident in Sweden 1989-2011 and with at least 1 cervical smear registered during the study period (n= 2,466,671). Follow-up of a first atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesion cytological diagnosis within 25 months was classified as repeat cytology, colposcopy/biopsy, or without further assessment. Incidence rate ratios and 95% confidence intervals of subsequent cervical cancer within 6.5 years following atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesion were estimated using Poisson regression by age group and management strategy. Women managed with repeat cytology within 6 months after atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion cytology had a similar risk of cervical cancer compared with colposcopy/biopsy (incidence rate ratio, 1.1, 95% confidence interval, 0.5-2.5, and incidence rate ratio, 2.0, 95% confidence interval, 0.6-6.5, respectively) among women aged 22-27 years. For women aged 28 years and older, women managed with repeat cytology had a higher risk for cervical cancer than women managed with colposcopy/biopsy. Our findings suggest that women with a first cytological diagnosis of atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesion up to age 27 years may indeed be safely followed up with repeat cytology within 6 months. A large amount of colposcopies that are currently performed in this group, therefore, could safely be discontinued.

Digital holographic microscopy as screening tool for cervical cancer preliminary study.

The liquid-based cytology Papanicolaou (Pap) test has gradually replaced the conventional Pap test, as it seems to be more efficient, in part because it uses computer assistance. However, Pap test diagnoses are still subjective and are cost-consuming or time-consuming. The authors describe a new digital holographic microscopy instrument and accompanying software. This technology provides an instantaneous, 3-dimensional image reconstruction of cells directly from the uterine cervical sample vial. Analyses were performed using the proprietary digital holographic microscopy (DHM) instrument, computer, and software. Residual materials from 3 randomly chosen laboratories were analyzed and subjected to DHM, and the sensitivity and specificity of DHM were calculated for the detection neoplasia. In 41 specimens that yielded normal Pap test results, 1333 cells were analyzed using DHM; and, in 30 specimens that yielded abnormal Pap test results, 494 cells were analyzed using DHM. Available histologic correlation was as follows: 4 histologic samples were diagnosed as grade 1 cervical intraepithelial neoplasia (corresponding to 2 cytologic diagnoses of low-grade squamous intraepithelial lesion and 2 cytologic diagnoses of atypical squamous cells of undetermined significance), 4 histologic samples were diagnosed as grade 3 cervical intraepithelial neoplasia (corresponding to 2 cytologic diagnoses of low-grade squamous intraepithelial lesion and 2 cytologic diagnosis of atypical squamous cells, cannot rule out high-grade squamous intraepithelial lesion), and 11 lesions were diagnosed as benign. Receiver operating characteristic curve analysis indicated that the best criteria were the nuclear-to-cytoplasmic ratio (area under the curve, 0.88; 95% confidence interval, 0.68-1.00) and the greatest nuclear dimension (area under the curve, 0.85; 95% confidence interval, 0.66-1.00). This preliminary study demonstrated for the first time that the DHM technique is suitable for the processing of gynecologic cervical samples. Nevertheless, DHM criteria and parameters could be better defined. Hopefully, holographic analysis will be performed automatically and will provide an instantaneous, cost-effective diagnosis from a closed vial with the preservation of all cellular material. Cancer Cytopathol 2016;124:573-80. © 2016 American Cancer Society.

総合病院 4 施設における ASC-H 判定の現状と問題点

目的 : 患者背景と診療体系が異なる総合病院 4 施設の ASC-H 判定の TBS 導入後 1 年目と 3 年目の経年的変化を調査し, 現状と問題点を明らかにする. 方法 : 主な被検者は A 施設は検診目的, B, C, D 施設は既病変者である. 各施設の TBS 導入 1 年目と 3 年目で 1) 検体件数と採取法, 2) ASC に対する ASC-H の割合, 3) ASC-H と判定した理由, 4) 生検施行率と診断, を調査した. 成績 : 採取法は 1 年目が綿棒, 3 年目ではブラシが主であった. ASC-H の割合は, A, B, C, D 施設で 1 年目が 13%, 33%, 30%, 22%, 3 年目では 9%, 38%, 37%, 25%であった. 判定理由は, 重積細胞集塊の核内構造が不明瞭, 細胞異型が HSIL に満たない, 癌治療の影響を伴う異型細胞で良悪判定が困難, であった. 生検施行率は 1 年目が 73%, 74%, 95%, 63%, 3 年目では 100%, 68%, 88%, 33%で, CIS が 3 年目で増加していた. 結論 : 主被検者が既病変者である施設は, 両年目ともに ASC-H の目標値である 10%を超えていた. ブラシ採取に起因した重積細胞集塊の判定に不慣れなこと, 癌治療後の異型細胞の良悪判定基準が不明確なことが問題点であった.

Triage of ASC-H: A meta-analysis of the accuracy of high-risk HPV testing and other markers to detect cervical precancer.

Women with a cytological diagnosis of atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H) are usually immediately referred for colposcopy. However, triage may reduce the burden of the diagnostic workup and prevent overtreatment. A meta-analysis was conducted to assess the accuracy of high-risk human papillomavirus (hrHPV) testing and testing for other molecular markers for the detection of grade 2 cervical intraepithelial neoplasia or worse (CIN2+) or grade 3 cervical intraepithelial neoplasia or worse (CIN3+) in women with ASC-H. An additional question that was assessed was whether triage would be useful in light of the relatively high pretriage probability of underlying precancer. The pooled absolute sensitivity and specificity of the Hybrid Capture 2 (HC2) assay for CIN2 + (derived from 19 studies) were 93% (95% confidence interval [CI], 89%-95%) and 45% (95% CI, 41%-50%), respectively. p16(INK4a) staining (only 3 studies) had similar sensitivity (93%; 95% CI, 75%-100%) but superior specificity (specificity ratio, 1.69) to HC2 for CIN2+. Testing for paired box 1 gene methylation (only 1 study) showed a superior specificity of 95% (specificity ratio, 2.08). The average pretest risk was 34% for CIN2 + and 20% for CIN3+. A negative HC2 result decreased this to 8% and 5%, respectively, whereas a positive result upgraded the risk to 47% and 28%, respectively. Because of the high probability of precancer with a diagnosis of ASC-H, the utility of triage is limited. The usual recommendation for referring women with ASC-H for colposcopy is not altered by a positive triage test, whatever test is used. A negative hrHPV DNA or p16(INK4a) test may allow repeat testing, but this recommendation will depend on local decision thresholds for referral.

Minor Cytological Abnormalities and up to 7-Year Risk for Subsequent High-Grade Lesions by HPV Type.

ObjectiveDiagnoses of atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesions (LSIL) are common, but the corresponding risk of disease varies by human papillomavirus (HPV) status, complicating management strategies. Our aim was to estimate the longer-term risk of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) among women with ASCUS/LSIL by age, HPV status, and genotype(s).MethodsA total of 314 women with ASCUS/ LSIL were followed for a median of 3.8 years. Baseline HPV status was determined by reflex testing and women with histologically confirmed CIN2+ were identified through linkage to the Swedish National Quality Register for Cervical Cancer Prevention. Cumulative incidence and hazard ratios were estimated to explore differences between index data and associations with CIN2+.ResultsIn total, 89 women (28.3%) developed CIN2+. High-risk (HR) HPV-positive women developed significantly more CIN2+ than HR-HPV-negative women (cumulative incidence 3.5 years after the index test: 42.2%, 95% CI: 32.5–53.5 for HPV16/18; 36.2%, 95% CI: 28.3–45.4 for other HR-HPV types; and 2.0%, 95% CI: 0.5–7.8 for HR-HPV-negative women; p<0.0001).ConclusionHPV status was of greatest importance in determining the risk of CIN2+. The risk was low among HPV-negative women during the first years of follow-up, suggesting these women could be followed less intensively. HPV16/18-positive women may need intensified follow-up as they showed the highest risk of CIN2+.

Long-term HPV type-specific risks for ASCUS and LSIL: A 14-year follow-up of a randomized primary HPV screening trial

Human papillomavirus (HPV) infections result in a significant burden of low-grade cervical lesions. Between 1997 and 2000, our randomized trial of primary HPV screening enrolled 12,527 women participating in population-based screening. Women between 32 and 38 years of age (median: 34, interquartile range: 33-37) were randomized to HPV and cytology double testing (intervention arm, n = 6,257 enrolled, n = 5,888 followed-up) or to cytology, with samples frozen for future HPV testing (control arm, n = 6,270 enrolled, n = 5,795 followed-up). We estimated the HPV type-specific, long-term absolute risks (AR), and population attributable proportions (PAR) for cytological diagnoses of atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesion (LSIL) and for histopathologically diagnosed cervical intraepithelial neoplasia grade 1 (CIN1). The women were followed using comprehensive, nationwide register-based follow-up. During a mean follow-up time of 11.07 years, 886 ASCUS and LSIL lesions were detected, 448 in the intervention arm and 438 in the control arm. Poisson regression estimated the incidence rate ratios (IRRs) of low-grade lesions by HPV type. The IRRs were strongly dependent on follow-up time. The IRRs for ASCUS/LSIL associated with high-risk HPV positivity were 18.6 (95% CI: 14.9-23.4) during the first screening round, 4.1 (95% CI: 2.8-6.2) during the second, 2.6 (95% CI: 1.7-4.1) during the third, and 1.1 (95% CI: 0.7-1.8) for >9 years of follow-up, with similar declines seen for the individual types. Type 16 contributed consistently to the greatest proportion of ASCUS, LSIL, and CIN1 risk in the population (first screening round PAR: ASCUS: 15.5% (95% CI: 9.7-21.9), LSIL: 14.7% (95% CI: 8.0-20.9), and CIN1: 13.4% (95% CI: 3.2-22.5)), followed by type 31 [8.4% (95% CI: 4.2-12.5) for ASCUS to 17.3% (95% CI: 6.8-26.6) for CIN1]. In summary, most ASCUS/LSIL lesions associated with HPV infection are caused by new HPV infections and most lesions are found during the first screening round.

Evaluation of a Low-Cost Liquid-Based Pap Test in Rural El Salvador

We sought to test the diagnostic efficacy of a low-cost, liquid-based cervical cytology that could be implemented in low-resource settings. A prospective, split-sample Pap study was performed in 595 women attending a cervical cancer screening clinic in rural El Salvador. Collected cervical samples were used to make a conventional Pap (cell sample directly to glass slide), whereas residual material was used to make the liquid-based sample using the ClearPrep method. Selected samples were tested from the residual sample of the liquid-based collection for the presence of high-risk Human papillomaviruses. Of 595 patients, 570 were interpreted with the same diagnosis between the 2 methods (95.8% agreement). There were comparable numbers of unsatisfactory cases; however, ClearPrep significantly increased detection of low-grade squamous intraepithelial lesions and decreased the diagnoses of atypical squamous cells of undetermined significance. ClearPrep identified an equivalent number of high-grade squamous intraepithelial lesion cases as the conventional Pap. High-risk human papillomavirus was identified in all cases of high-grade squamous intraepithelial lesion, adenocarcinoma in situ, and cancer as well as in 78% of low-grade squamous intraepithelial lesions out of the residual fluid of the ClearPrep vials. The low-cost ClearPrep Pap test demonstrated equivalent detection of squamous intraepithelial lesions when compared with the conventional Pap smear and demonstrated the potential for ancillary molecular testing. The test seems a viable option for implementation in low-resource settings.

Testing of Integrated Human Papillomavirus mRNA Decreases Colposcopy Referrals: Could a Change in Human Papillomavirus Detection Methodology Lead to More Cost-Effective Patient Care?

Objectives: This study investigates potential colposcopy referral rates, as per the latest American Society for Colposcopy and Cervical Pathology recommendations, following the change in high-risk human papillomavirus (HR-HPV) detection methodology from Hybrid Capture 2 (HC2) to APTIMA at our institution. Study Design: Rates of colposcopy referral were compared between two cohorts, each comprising all Pap samples with a diagnosis of atypical squamous cells of undetermined significance (ASCUS) tested for HR-HPV in our laboratory during a 12-month period. Cohorts I and II included Pap samples tested with HC2 (n = 1,856) and APTIMA (n = 1,651), respectively. The rates of quantity not sufficient (QNS) results were determined for all Pap samples during the same time periods. Results: The proportion of HR-HPV-positive Pap samples with an ASCUS diagnosis was significantly lower with APTIMA (42%) than with HC2 (53%; p < 0.0001). APTIMA also resulted in a significantly lower QNS rate among all Pap samples (0.42 vs. 4.3% with HC2; p < 0.0001). Conclusion: The change in HR-HPV detection methodology from HC2 to APTIMA has led to a 21% reduction in colposcopy referrals and a 90% decrease in QNS rates at our institution. The new methodology has resulted in more cost-effective patient care and fewer insufficient samples requiring repeat HR-HPV testing.