Negative Cervical Biopsies Research Articles

Risk for Cervical Intraepithelial Neoplasia Grade 3 or Higher in Follow-Up of Women With a Negative Cervical Biopsy

The Norwegian Cervical Cancer Screening Programme recommends follow-up of histologically confirmed normal/cervical intraepithelial neoplasia (CIN) 1 with combined cytology and human papillomavirus testing within 6 to 12 months. This study examines adherence to guidelines and subsequent risk for CIN 3+ within this subset of women. Women aged 25 to 69 years attending the Norwegian Cervical Cancer Screening Programme in Norway's 2 northernmost counties were included. An exposed cohort with histologically confirmed normal/CIN 1 after an atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesion or atypical squamous cells - cannot exclude high-grade squamous intraepithelial lesion/high-grade squamous intraepithelial lesion enrolment cytology (n = 374) was compared with a nonexposed cohort with a normal enrolment cytology attending primary screening (N = 25,948). Risk calculations were stratified by outcomes of the first follow-up cytology. The study end point was CIN 3+ or censored at 78 months of follow-up. In the exposed cohort, the 42-month cumulative incidence of CIN 3+ was 9.4% (95% CI = 4.1-14.7) for women with an abnormal first follow-up cytology and 1.6% (95% CI = 0.0-3.4) for women with a normal first follow-up cytology versus 0.21% (95% CI = 0.15-0.27) in the nonexposed cohort (p < .01). The CIN 3+ risk was higher in the exposed cohort when the first follow-up cytology was abnormal (hazard ratio = 20.4, 95% CI = 11.2-37.1) compared with normal (hazard ratio = 4.7, 95% CI = 1.9-11.6) with the nonexposed cohort as reference. After a negative cervical biopsy, a normal first follow-up cytology provided a CIN 3+ risk considered acceptable to recommend return to routine screening in 3 years. Cytology and human papillomavirus co-testing in post-colposcopy follow-up of negative biopsies may improve risk stratification.

Utility of p16 Immunohistochemistry in Evaluating Negative Cervical Biopsies Following High-risk Pap Test Results.

The Lower Anogenital Squamous Terminology (LAST) Standardization Project for human papilloma virus (HPV)-associated lesions specifically recommends the use of p16 immunohistochemistry (IHC) as an adjunct to morphologic assessment of cervical biopsies interpreted as negative or low-grade squamous intraepithelial lesion (LSIL) from patients with prior high-risk Pap test results (high-grade squamous intraepithelial lesion [HSIL], atypical squamous cells cannot exclude HSIL, atypical glandular cells [AGC], or HPV16 atypical squamous cells of undetermined significance [ASC-US]). The impetus for this recommendation is to increase detection of missed high-grade disease. However, the quality of evidence supporting this recommendation was lower than that for the other LAST recommendations addressing improved consistency in the diagnosis of HSIL with the use of p16. A database search spanning 10 years identified 341 cases (encompassing 736 discrete biopsy specimens) interpreted as negative for dysplasia from 330 patients with a prior high-risk Pap result (atypical squamous cells cannot exclude HSIL, HSIL, atypical glandular cells, not otherwise specified [AGC-NOS], atypical endocervical cells--NOS [AEC-NOS], and AEC-favor neoplastic). p16 IHC was performed and detected missed abnormalities in 11/341 (3.2%) cases. The abnormalities corresponded to missed foci of HSIL (cervical intraepithelial neoplasia [CIN] 2) (n=1), SIL-indeterminate grade (n=7), atypical squamous metaplasia (n=2), and LSIL [CIN1]) (n=1). Subsequent histologic follow-up identified HSIL or greater in 6/8 (75%) p16 cases versus 20/79 (25.3%) p16 cases (P=0.0079). p16 IHC performed on biopsies interpreted as negative from patients with prior high-risk Pap test results increased the detection rate of missed SIL. A p16 result also significantly increased the likelihood of HSIL on subsequent biopsy. Although further studies are required to determine what percentage of missed HSIL justifies the additional cost, improved detection of HSIL in high-risk patients may lead to fewer diagnostic procedures and fewer patients lost to follow-up.

Abstract 433: Utility of p16 immunohistochemistry in evaluating negative cervical biopsies following high-risk pap test results

Abstract The Lower Anogenital Squamous Terminology (LAST) Standardization Project for HPV-associated Lesions recommends the use of p16 immunohistochemistry as an adjunct to morphologic assessment of cervical biopsies interpreted as negative from patients that are at high risk for missed high-grade disease (defined as a prior cytologic interpretation of HSIL, ASC-H, ASC-US/HPV-16+, or AGC-NOS) (Darragh et al., 2012). However, few studies have specifically evaluated the utility of performing p16 on negative cervical biopsies and endocervical curettage specimens following high-risk Pap test results. A search of the Stanford Cytopathology database from 7/1/2002-6/30/2012 for cervical cytology cases with diagnoses of ASC-H, HSIL, AGC-NOS, and atypical endocervical cells NOS (AGC-EC) yielded 1517 cases. Of these, 703 cases had histologic follow-up. Biopsies were excluded if diagnosed as atypical, low grade squamous intraepithelial lesion (LSIL), high grade squamous intraepithelial lesion (HSIL), or insufficient, or if the time to follow up was greater than 1 year. Immunostain for p16 (CINtec) was performed on 350 cases from 339 patients (age 16-85 yrs, average 42+/-14) and scored as positive (diffuse strong), negative or equivocal. 6 cases were excluded due to insufficient tissue and 3 cases with equivocal staining were excluded from further analysis. For p16(+) and equivocal cases, HPV in situ hybridization (ISH) (Ventana HPV III Family 16 probe) was performed and the corresponding H&amp;E section reviewed. Based on the H&amp;E review, the diagnosis was revised. Follow-up data was also obtained. 12/341 cases (3.5%) were p16(+) corresponding to missed diagnoses of LSIL (1 cases), HSIL-CIN2 (2 cases), and SIL-indeterminate grade (6 cases). Two biopsies from one patient at different time points exhibited p16 staining of bland metaplastic cells undermining endocervical glands that morphologically did not meet criteria for SIL and were interpreted as atypical metaplasia. Follow-up biopsies showed HSIL. p16 immunostain increases the detection rate of SIL by 3.5% in benign appearing cervical biopsies and endocervical curettages from patients with a prior high-risk Pap test result. The benefit of p16 immunostain is highest for cases with a prior Pap diagnosis of HSIL. Cytoplasmic only staining and staining of surface mucosa, endocervical glands, and tubal metaplasia may lead to over-interpretation of p16 as positive. Reference: Darragh, T. M. et al. The Lower Anogenital Squamous Terminology Standardization Project for HPV-Associated Lesions: background and consensus recommendations from the College of American Pathologists and the American Society for Colposcopy and Cervical Pathology. Arch. Pathol. Lab. Med. 136, 1266-1297 (2012). Citation Format: Alana F. Shain, Shirley Kwok, Ann K. Folkins, Christina S. Kong. Utility of p16 immunohistochemistry in evaluating negative cervical biopsies following high-risk pap test results. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 433.

HPV E6/E7 mRNA Testing Is More Specific than Cytology in Post-Colposcopy Follow-Up of Women with Negative Cervical Biopsy

BackgroundIn Norway, women with negative or low-grade cervical biopsies (normal/CIN1) are followed up after six months in order to decide on further follow-up or recall for screening at three-year intervals. A high specificity and positive predictive value (PPV) of the triage test is important to avoid unnecessary diagnostic and therapeutic procedures whereas a low risk of high-grade disease among triage negative women assures safety.Materials and MethodsAt the University Hospital of North Norway, cytology and the HPV mRNA test PreTect HPV-Proofer, detecting E6/E7 mRNA from HPV types 16, 18, 31, 33 and 45, are used in post-colposcopy follow-up of women with negative or low-grade biopsy. In this study, women with negative biopsy after high grade cytology (ASC-H/HSIL) and/or positive HPV mRNA test in the period 2005–2009 were included (n = 520). Histologically confirmed cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) was used as study endpoint.ResultsOf 520 women with negative or low-grade biopsy, 124 women (23.8%) had CIN2+ in follow-up biopsy. The sensitivity and specificity of the HPV mRNA test were 89.1% (95% CI, 80.1–98.1) and 92.5% (95% CI, 88.2–96.7), respectively. The ratios of sensitivity, specificity and PPV of HPV mRNA testing compared to repeat cytology for finding CIN2+ was 1.05 (95% CI: 0.92–1.21), 1.21 (95% CI: 1.12–1.32), and 1.49 (95% CI: 1.20–1.86), respectively. The PPV of mRNA was 77.3% (95% CI, 59.8–94.8) in women aged 40 or older.ConclusionWomen with negative cervical biopsy require follow-up before resumption of routine screening. Post-colposcopy HPV mRNA testing was as sensitive but more specific than post-colposcopy cytology. In addition, the HPV mRNA test showed higher PPV. A positive mRNA test post-colposcopy could justify treatment in women above 40 years.

Patients with negative cervical biopsies after papanicolaou test interpretations of “atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion”: comparative longitudinal follow-up

Approximately half of women with a Papanicolaou (pap) test interpretation of "atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion" (ASC-H) will have less than a high-grade dysplasia diagnosed on their follow-up cervical biopsy sample. Herein, we compared the follow-up findings in a group of women with a negative cervical biopsy after a pap test interpretation of ASC-H (study group) with those of a randomly selected control group of women whose pap tests were interpreted as "negative for intraepithelial lesion or malignancy" during the same period. The diagnoses in every follow-up sample in the control and study groups were tabulated. Patients with previous ASC-H or high-grade squamous intraepithelial lesion interpretations, and/or high-grade cervical intraepithelial neoplasia (CIN) diagnoses, were excluded. Both groups were then statistically compared regarding the diagnostic frequencies of each of the Bethesda 2001 categories and CIN grades. Of the 122 patients with ASC-H interpretations and documented histologic follow-up, the first follow-up biopsy was negative for dysplasia in 20 (16.4%). Seventy-six follow-up samples (70 pap tests, 6 biopsies) were obtained from these 20 patients. In the control group of 262 women with pap tests interpreted as "negative for intraepithelial lesion or malignancy," 641 follow-up samples (629 pap tests, 12 biopsies) were obtained. Patients in the study group were significantly more likely than their control group counterparts to have a follow-up (1) cytologic and/or histologic abnormality (23/76 vs 76/641, respectively; P = .00006), (2) "atypical squamous cells of undetermined significance" (ASC-US) interpretation (13/76 vs 43/641; P = .005), and (3) CIN grade 1 diagnosis (4/76 vs 10/641; P = .05). Approaching statistical significance was the comparatively increased frequency of CIN grade 2 to 3 diagnoses in the study group (2/76 vs 2/641; P = .058). If the analysis is restricted to 1 follow-up sample (the most severe) per patient, patients in the study group were still more likely than those in the control group to have a follow-up cytologic and/or histologic abnormality (12/20 vs 40/262; P = .0002), ASC-US interpretation (6/20 vs 22/262; P = .008), and follow-up CIN grade 2 to 3 diagnosis (2/20 vs 2/262; P = .03). It is concluded that patients whose cervical biopsies are devoid of dysplasia after an ASC-H interpretation still require close surveillance and follow-up because their risk of being diagnosed with follow-up cervical abnormalities is significantly above baseline.

Noncorrelating Pap tests and cervical biopsies: Histological predictors of subsequent correlation

Lack of correlation between dysplastic cervicovaginal Papanicolaou (Pap) tests and subsequent cervical biopsies raises the concern that a significant squamous intraepithelial lesion (SIL) may go unconfirmed. Additional tissue sections of cervical biopsies may detect SILs after noncorrelation on initial sections. Complete step sectioning of paraffin blocks was undertaken on 111 noncorrelating biopsy specimens from 95 patients and selected slides were reviewed for the presence of SIL. The initial negative biopsy slides were evaluated for four histological features: chronic cervicitis, acute cervicitis, mucosal erosion, and squamous atypia. Twenty-seven biopsies (24.3%) demonstrated the presence of a SIL in deeper levels. The presence of squamous atypia was significantly associated with the presence of dysplasia deeper in the block (P < 0.002). Acute and chronic cervicitis was seen roughly equally. Additional tissue levels are a productive way of confirming SILs, and squamous atypia allows a refined selection of negative cervical biopsies most likely to reveal an SIL on review of deeper levels.

Significance of Extensive Hyperkeratosis on Cervical/Vaginal Smears

To assess the significance of reporting hyperkeratosis on cervical/vaginal (CV) smears. Cases diagnosed with extensive hyperkeratosis (E-HK) and without prior or concurrent history of neoplasia, squamous intraepithelial lesion or atypical squamous cells of undetermined significance (ASCUS) were retrieved from our files for the period January 1994-August 2001. E-HK is defined in our practice as patches of anucleated squames with irregular, angulated edges present in at least 5 low-power (10 x eyepiece and 10 x objective) fields on a conventional CV smear. On liquid-based preparations, we use 3 low-power fields. Only cases with a follow-up CV smear and/or cervical biopsy (CB) were selected. Among 328 cases of E-HK, 138 patients met the study selection criteria. Eighty-one cases had negative CV smears and/or CB, 17 (12.3%) patients had persistent E-HK, and a subsequent diagnosis of ASCUS or higher was made in 40 patients (28.9%). Among the 40 cases with subsequent abnormalities, 13 (9.4%) were diagnosed with ASCUS, 24 (17.4%) with HPV or dysplasia, and 3 (2.1%) with malignancy. While isolated, anucleate squames may have no clinical importance in patient management, E-HK can be a significant marker of underlying neoplastic disease. This should be kept in mind as one decides how to report CV cytology based on 2001 Bethesda System recommendations.

False Positive Cervicovaginal Cytology

To determine what percentage of cervical cytologic diagnoses initially classified as false positives (based on a negative cervical biopsy within three months of the cervical cytologic smear) are recategorized as histologic false negatives when subsequent studies reveal abnormalities. A three-year review of 1,242 cervicovaginal biopsies with corresponding cytology in the preceding three months revealed 68 cases (5.5%) where the cytology was positive for a squamous intraepithelial lesion but the biopsy was within normal limits or showed benign cellular changes. Follow-up cytologic and/or histologic diagnoses were obtained for 53 of the 68 cases from the patients' hospital and physician office records. Of the 53 cases with follow-up, 24 (45%) were found to have a subsequent squamous intraepithelial lesion (indicating a sampling error at the time of the initial biopsy), and 9 showed atypical squamous cells of undetermined significance. In addition, 9 of the 20 patients (45%) who had negative follow-up studies had benign abnormalities on the initial, noncorrelating biopsy that may have contributed to the discrepancy. This study emphasized the importance of diligent follow-up of patients with noncorrelating studies since they represent a population at high risk for the subsequent detection of premalignant conditions.

Evaluation of the cytologic test in the early diagnosis of cancer: A two-year survey of the routine use of the smear technique

1.1. In 1946 and 1947, in the Strang Clinic of Memorial Hospital, approximately 8,000 asymptomatic women had routine vaginal and cervical smears for the detection of cancer of the genital tract. The method as applied in the clinic is discussed.2.2. The significant features of the criteria of malignancy as seen in cytologic studies are evaluated.3.3. A classification of the findings on smears as applied to the diagnosis of malignant neoplasm is presented.4.4. Our findings result in twenty-two positive cases of carcinoma of the female genital tract, which is approximately one case per 354 asymptomatic women examined. Twenty-one cases were substantiated by biopsies. The remaining case continues positive smears in spite of repeated negative cervical biopsies. One case showed negative smears prior to the positive cervical biopsy although the surgically removed uterus showed only adenosis.