Janet F. Stastny

Atypical epithelial cells and specimen adequacy: Current laboratory practices of participants in the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology

○ Context.-The Bethesda System for reporting cervical/ vaginal cytologic diagnoses introduced terminology for atypical squamous and glandular cells and categories for specimen adequacy. Objectives.-To analyze current laboratory reporting practices and compare trends to previous surveys. Design.-Questionnaire surveys were mailed to 2000 laboratories in 1996 and 1997. Participants.-Laboratories enrolled in the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology. Main Outcome Measures.-Laboratory policies, criteria, and reporting rates for Bethesda System categories. Results.-The 1996 specimen adequacy survey had 1166 respondents, and 768 laboratories returned the 1997 questionnaire focusing on atypical squamous cells of undetermined significance (ASCUS) and glandular cells of undetermined significance (AGUS). Nearly all laboratories (92%) routinely reported specimen adequacy, an increase from the 66% rate in 1991. The median rate for unsatisfactory specimens was 0.5% (mean 0.95%), and the median rate for the satisfactory but limited category was 5.8% (mean 9.3%). The Bethesda criteria for designating a specimen unsatisfactory were used by more than 90% of laboratories. Nearly all laboratories (97%) used the term ASCUS in 1997, and more than 80% of laboratories used the Bethesda criteria for this category. Median reporting rates for epithelial abnormalities were as follows: ASCUS, 4.5%; AGUS, 0.3%; low-grade squamous intraepithelial lesion (SIL), 1.6%; and high-grade SIL, 0.5%. The median ASCUS/SIL ratio was 2.0, with 80% of laboratories reporting ratios between 0.64 and 4.23. The median ASCUS rate and ASCUS/SIL ratio were higher than 1993 survey results. Nearly all laboratories attempted follow-up studies on patients with abnormal cytology results, and midsized laboratories achieved the highest rates of follow-up. Median rates of abnormalities following an ASCUS or AGUS diagnosis were 20% and 15%, respectively. Laboratory respondents commonly used written recommendations in ASCUS/AGUS reports. Conclusions.-Most laboratories that responded to the surveys had adopted Bethesda terminology and criteria for specimen adequacy and ASCUS/AGUS. Reporting rates for SIL and adequacy categories have remained stable, but median ASCUS rates and ASCUS/SIL ratios are higher than in 1993. The AGUS category is reported infrequently, but can be associated with significant pathology.

Comparison of the costs of fine-needle aspiration and open surgical biopsy as methods for obtaining a pathologic diagnosis

A pathologic diagnosis is usually required to determine definitive management for a palpable lesion. In this era of cost control, fine‐needle aspiration (FNA) provides a low‐cost alternative to open excisional biopsy. Using a broad range of cases collected over 20 years, the authors of this study sought to quantify the savings resulting from the use of FNA on superficial palpable lesions to obtain a pathologic diagnosis.

Interobserver variability in subclassification of squamous intraepithelial lesions: Results of the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology.

OBJECTIVE To determine whether, on a national cytology proficiency test, a competent cytologist can consistently distinguish grades of squamous intraepithelial lesions. DESIGN Results for low- and high-grade squamous intraepithelial lesion referenced slides from the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology for 1996 and 1997 were analyzed including educational, nongraded vs graded validated slides. RESULTS The discrepant rate between low- and high- grade lesions ranged from 9.8% to 15% for cytotechnologist, pathologist, laboratory, and all responses. There was a statistically significant difference in performance on graded, validated slides vs educational slides with better performance on validated slides. CONCLUSION This significant interobserver variability in subclassification of squamous lesions should be considered in management guidelines for abnormal Papanicolaou test results and implementation of national cytology proficiency testing.

Cytologic Features of Sinus Histiocytosis with Massive Lymphadenopathy

BACKGROUND Sinus histiocytosis with massive lymphadenopathy (SHML) was described over 20 years ago by Rosai and Dorfman. Originally it was described as occurring in young males, predominantly with cervical lymphadenopathy. Since then over 423 histologically documented cases of SHML have been documented, including many extranodal sites. Few studies have characterized the cytologic features of SHML. CASE Three cases of lymph node involvement by SHML occurred, one also with skin involvement. Cytologic findings included numerous histiocytes with phagocytized lymphocytes, atypical forms of histiocytes and a reactive, lymphoid background. Surgical biopsy and immunohistochemical stain for S-100 protein of all three cases confirmed the cytologic impression. CONCLUSION Sinus histiocytosis with massive lymphadenopathy can be diagnosed by cytology in conjunction with clinical history and immunohistochemistry.

Cytologic features of necrotizing granulomatous inflammation consistent with cat-scratch disease.

Approximately 2,000 cases of cat‐scratch disease are reported annually. It is an uncommon cause of unilateral lymphadenopathy in children and adults. We present the cytologic features of necrotizing granulomatous lesions consistent with cat‐scratch disease from various sites. Eleven cases from 10 patients with a mean age of 16 yr (range, 2–33 yr) were biopsied by fine‐needle aspiration. All gave a history of previous exposure to cats. Two children had atypical presentations; one with multiple hypodense areas within the liver and spleen, and the other with features of encephalitis. Other locations included lymph nodes from axilla, inguinal, preauricular, and cervical areas, and other body sites such as the scapula and the parotid gland. Histologic staging of the inflammatory process was correlated with cytologic features. There were 5 cases of early features, 3 cases in the middle phase, and 3 cases in late stage. The differential diagnosis of each stage is discussed. The 2 children with atypical presentations are described in detail. Diagn Cytopathol 1996;15:108–115.

Primary lymphoma of the endometrium. A report of two cases diagnosed on cervicovaginal smears.

BACKGROUND Primary lymphomas of the endometrium are extremely rare. Diagnosis is difficult, especially when the neoplasm is originally evaluated on a cervicovaginal smear. When lymphomas involve the endometrium, the cervix is three times more likely to be the primary site rather than the endometrium. Two of the symptoms of primary lymphoma of the endometrium are abnormal vaginal bleeding and an abdominal or pelvic mass. CASES Case 1 was a 36-year-old, obese, black female with an abdominal mass and recent onset of ascites. The second case was a 31-year-old, obese, black female with a history of menometrorrhagia. The cytologic findings in both cases revealed an individual cell population, high nuclear/cytoplasmic ratio, small nucleoli and coarsely granular chromatin with some chromatin clearing. Endometrial currettings showed a histologic pattern of malignant non-Hodgkins lymphoma, diffuse, large cell type. Immunoperoxidase staining was positive for leukocyte common antigen. CONCLUSION Two cases of lymphoma of the endometrium were diagnosed first by a cervical cytologic smear, supported by a positive body cavity fluid in one case and histology in both. The differential diagnoses included various inflammatory lesions, small cell carcinoma, endometrial stromal sarcoma and granulocytic sarcoma.

Solitary Splenic Metastasis of an Adenocarcinoma of the Ovaries

Metastatic involvement of the spleen by carcinoma occurs in a setting of widespread malignant disease. Solitary splenic metastasis in the absence of disseminated disease is rare. We report a case of a 55-year-old woman in whom the sole clinical manifestation of recurrent papillary serous cystadenocarcinoma of the ovary was an elevated serum CA125 level due to a solitary splenic metastasis.

Adenoid basal carcinoma of the cervix: A potential pitfall in cervicovaginal cytology

Adenoid basal carcinoma (ABC) of the cervix is a quite uncommon, indolent, yet invasive neoplasm rarely identified on cervico‐vaginal smears. This may be due in part to sampling. Unless ABCs become ulcerated, even vigorous brushing of the endocervical canal may not be adequate to dislodge the small, cohesive cells of this neoplasm. Fortunately, the association of ABC with squamous intraepithelial lesions (SIL) often results in its incidental diagnosis on follow‐up cervical biopsy or endocervical curettage. We report two cases of ABC. In case 1, a 79‐yr‐old white woman was diagnosed with squamous‐cell carcinoma on cervicovaginal (CV) smear. High‐grade SIL, carcinoma in situ, and ABC were identified on subsequent cervical cone biopsy and hysterectomy. Retrospective evaluation of the CV smear revealed a few aggregates of small, uniform cells, with hyperchromatic nuclei representing fragments of ABC. In case 2, atypical basaloid cells suspicious for ABC were recognized on the CV smear of a 67‐yr‐old black woman, and ABC was subsequently confirmed on cervical cone biopsy. In neither case did the intervening cervical biopsy reveal ABC. In addition to a review of the clinical information useful in the diagnosis of ABC, the cytologic features of these two cases are compared with their subsequent histopathology and contrasted with other similar lesions comprising the differential diagnosis of small neoplastic cells found in cervicovaginal smears. Diagn Cytopathol 1996;14:172–177.

Condyloma and Cervical Intraepithelial Neoplasia of the Endometrium

Many studies have shown the presence of squamous metaplasia, dysplasia, carcinoma in situ and squamous cell carcinoma of the endometrium, whether they arose de novo or from direct extension from the cervix. Condyloma associated with squamous metaplasia or dysplasia of the endometrium is rare. We report a case of cervical intraepithelial neoplasia (CIN I) and condyloma of the endometrium. A 58-year-old woman presented with high-grade dysplasia on two successive pap smears. A total vaginal hysterectomy showed extensive CIN I and condyloma involving the entire endometrium. DNA in situ hybridization and polymerase chain reaction documented the presence of condyloma.

Transitional-cell carcinoma metastatic to cerebrospinal fluid: presentation of two cases.

We present 11 specimens from 2 patients with transitional cell carcinoma metastatic to the cerebrospinal fluid. This is a rare occurrence documented in one previous report in which 5 patients had 28 specimens reviewed (Ehya et al., Acta Cytol 1981;25:599–610). Cytologic features that most likely indicate a bladder origin are the cytoplasmic tails and cytoplasmic pseudopod formation. Diagn Cytopathol 1996;15:338–340.