Clinical Significance of Atypical Squamous Cells, Cannot Exclude High Grade
We used cytohistologic correlation to determine the clinical significance of atypical squamous cells, cannot exclude high grade (ASC-H), in perimenopausal and postmenopausal women. A computer search identified 250 Papanicolaou smears from women older than 45 years with a diagnosis of ASC-H. Cases were considered perimenopausal (45 to <55 years; 150 cases) and postmenopausal (B355 years; 100 cases). No follow-up data were available for 33 cases, which were excluded. The remaining 217 cases (perimenopausal, 127; postmenopausal, 90) had surgical or cytologic follow-up. Results of follow-up colposcopic biopsy were available for 176 (81.1%) and cytology for 41 (18.9%) women. Follow-up results were as follows: perimenopausal women, negative, 50 (39.4%); mild dysplasia (low-grade squamous intraepithelial lesion [LSIL]), 46 (36.2%); high-grade dysplasia (high-grade SIL [HSIL]); 28 (22.0%); and ASC of undetermined significance (ASC-US), 3 (2.4%); postmenopausal women, negative, 52 (58%); LSIL, 31 (34%); HSIL, 5 (6%); and ASC-US, 2 (2%). The diagnosis of ASC-H in postmenopausal women usually is associated with LSIL or a negative diagnosis on follow-up, suggesting a less aggressive surveillance and treatment regimen is needed for postmenopausal women with ASC-H.
The Bethesda System (TBS) was established to facilitate communication between cytopathologists and clinicians for appropriate management of patients. The recognition that high-grade dysplasia (high-grade squamous intraepithelial lesion [HSIL]) is likely to progress to invasive cancer, whereas most low-grade lesions regress spontaneously, raises awareness that eradicating HSIL is critical for cancer prevention. This knowledge has prompted efforts to improve early detection of HSIL.
Although most women with atypical squamous cells do not require immediate colposcopic examination or aggressive management, 5% to 10% of them might harbor an underlying HSIL, which requires immediate therapy. TBS (2001) classifies atypical squamous cells into 2 subcategories: atypical squamous cells of undetermined significance (ASC-US) and atypical squamous cells, cannot exclude high grade (ASC-H). This classification became necessary to facilitate cost-effective clinical management. Previous studies have reported that ASC-H is associated with a significant incidence of HSIL on follow-up compared with ASC-US. However, the rate of concurrent and subsequent HSIL in biopsy specimens from patients with ASC-H in the literature ranged from 29% to 75%.
Owing to demographics in the United States and the nature of cervical cancer, the majority of women participating in Papanicolaou (Pap) smear screening are younger than 50 years. It is estimated that by the next decade, postmenopausal women will constitute about one fifth of the adult population. Therefore, the number of postmenopausal patients subjected to Pap smears most likely will increase because the majority of these women will be familiar with having annual Pap smears.
A number of investigators have studied the diagnosis of squamous atypia in postmenopausal women and have had conflicting results. Most studies demonstrated that squamous atypia in postmenopausal women rarely is associated with biopsy-proven dysplasia or human papillomavirus (HPV) DNA detection. Certain specific problems are associated with the assessment of specimens from postmenopausal women, which can be diagnostically challenging. Artifactual alterations, ranging from drying and inflammatory changes, reactive metaplasia, presence of naked nuclei, and pseudoparakeratosis to sampling problems, are common in cervicovaginal smears from postmenopausal women. These alterations may lead to the overdiagnosis of squamous atypia. In addition, estrogen deficiency may lead to cytologic changes that mimic high-grade disease. The significance of ASC-H diagnoses in postmenopausal women remains unclear and not fully studied. With the increase in older women in the population, it is important to determine the clinical implications of ASC-H in postmenopausal women.
The purpose of the present study was to evaluate the clinical significance of reporting ASC-H on cervical samples processed by the ThinPrep (Cytyc, Boxborough, MA) technique in postmenopausal women in comparison with perimenopausal women.
We used cytohistologic correlation to determine the clinical significance of atypical squamous cells, cannot exclude high grade (ASC-H), in perimenopausal and postmenopausal women. A computer search identified 250 Papanicolaou smears from women older than 45 years with a diagnosis of ASC-H. Cases were considered perimenopausal (45 to <55 years; 150 cases) and postmenopausal (B355 years; 100 cases). No follow-up data were available for 33 cases, which were excluded. The remaining 217 cases (perimenopausal, 127; postmenopausal, 90) had surgical or cytologic follow-up. Results of follow-up colposcopic biopsy were available for 176 (81.1%) and cytology for 41 (18.9%) women. Follow-up results were as follows: perimenopausal women, negative, 50 (39.4%); mild dysplasia (low-grade squamous intraepithelial lesion [LSIL]), 46 (36.2%); high-grade dysplasia (high-grade SIL [HSIL]); 28 (22.0%); and ASC of undetermined significance (ASC-US), 3 (2.4%); postmenopausal women, negative, 52 (58%); LSIL, 31 (34%); HSIL, 5 (6%); and ASC-US, 2 (2%). The diagnosis of ASC-H in postmenopausal women usually is associated with LSIL or a negative diagnosis on follow-up, suggesting a less aggressive surveillance and treatment regimen is needed for postmenopausal women with ASC-H.
The Bethesda System (TBS) was established to facilitate communication between cytopathologists and clinicians for appropriate management of patients. The recognition that high-grade dysplasia (high-grade squamous intraepithelial lesion [HSIL]) is likely to progress to invasive cancer, whereas most low-grade lesions regress spontaneously, raises awareness that eradicating HSIL is critical for cancer prevention. This knowledge has prompted efforts to improve early detection of HSIL.
Although most women with atypical squamous cells do not require immediate colposcopic examination or aggressive management, 5% to 10% of them might harbor an underlying HSIL, which requires immediate therapy. TBS (2001) classifies atypical squamous cells into 2 subcategories: atypical squamous cells of undetermined significance (ASC-US) and atypical squamous cells, cannot exclude high grade (ASC-H). This classification became necessary to facilitate cost-effective clinical management. Previous studies have reported that ASC-H is associated with a significant incidence of HSIL on follow-up compared with ASC-US. However, the rate of concurrent and subsequent HSIL in biopsy specimens from patients with ASC-H in the literature ranged from 29% to 75%.
Owing to demographics in the United States and the nature of cervical cancer, the majority of women participating in Papanicolaou (Pap) smear screening are younger than 50 years. It is estimated that by the next decade, postmenopausal women will constitute about one fifth of the adult population. Therefore, the number of postmenopausal patients subjected to Pap smears most likely will increase because the majority of these women will be familiar with having annual Pap smears.
A number of investigators have studied the diagnosis of squamous atypia in postmenopausal women and have had conflicting results. Most studies demonstrated that squamous atypia in postmenopausal women rarely is associated with biopsy-proven dysplasia or human papillomavirus (HPV) DNA detection. Certain specific problems are associated with the assessment of specimens from postmenopausal women, which can be diagnostically challenging. Artifactual alterations, ranging from drying and inflammatory changes, reactive metaplasia, presence of naked nuclei, and pseudoparakeratosis to sampling problems, are common in cervicovaginal smears from postmenopausal women. These alterations may lead to the overdiagnosis of squamous atypia. In addition, estrogen deficiency may lead to cytologic changes that mimic high-grade disease. The significance of ASC-H diagnoses in postmenopausal women remains unclear and not fully studied. With the increase in older women in the population, it is important to determine the clinical implications of ASC-H in postmenopausal women.
The purpose of the present study was to evaluate the clinical significance of reporting ASC-H on cervical samples processed by the ThinPrep (Cytyc, Boxborough, MA) technique in postmenopausal women in comparison with perimenopausal women.
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