A potpourri of ASC-H and related interpretations- (Part I)

1. Morphological Evaluation of Twilight Zone in Cervical Cytology. Vinod B. Shidham , MD, FRCPath, FIAC Professor Executive editor & co-editor-in-chief, CytoJournal ( www.cytojournal.com ) Director- Cytopathology Fellowship Training Program & FNA Service Department of Pathology Medical College of Wisconsin 9200 W Wisconsin Av, Milwaukee, WI 53226, USA [email_address] (Nov 11, 2008, 1.35 to 2.15) Part I

2. http://bethesda2001.cancer.gov/terminology.html

3. SQUAMOUS CELL Atypical squamous cells - of undetermined significance ( ASC-US ) - cannot exclude HSIL ( ASC-H ) Low grade squamous intraepithelial lesion ( LSIL ) encompassing : HPV/mild dysplasia/CIN 1 High grade squamous intraepithelial lesion ( HSIL ) encompassing : moderate and severe dysplasia, CIS/CIN 2 and CIN 3 - with features suspicious for invasion ( if invasion is suspected) Squamous cell carcinoma GLANDULAR CELL AGUS Atypical (NOS) - endocervical cells (NOS or specify in comments) - endometrial cells (NOS or specify in comments) - glandular cells (NOS or specify in comments) Atypical (favor neoplastic) - endocervical cells, favor neoplastic - glandular cells, favor neoplastic Endocervical adenocarcinoma in situ Adenocarcinoma - endocervical, endometrial, extrauterine, and not otherwise specified (NOS) OTHER MALIGNANT NEOPLASMS: ( specify) EPITHELIAL CELL ABNORMALITIES

4. http://nih.techriver.net/

5. SQUAMOUS CELL Atypical squamous cells - of undetermined significance ( ASC-US ) - cannot exclude HSIL ( ASC-H ) Low grade squamous intraepithelial lesion ( LSIL ) encompassing : HPV/mild dysplasia/CIN 1 High grade squamous intraepithelial lesion ( HSIL ) encompassing : moderate and severe dysplasia, CIS/CIN 2 and CIN 3 - with features suspicious for invasion ( if invasion is suspected) Squamous cell carcinoma GLANDULAR CELL AGUS Atypical (NOS) - endocervical cells (NOS or specify in comments) - endometrial cells (NOS or specify in comments) - glandular cells (NOS or specify in comments) Atypical (favor neoplastic) - endocervical cells, favor neoplastic - glandular cells, favor neoplastic Endocervical adenocarcinoma in situ Adenocarcinoma - endocervical, endometrial, extrauterine, and not otherwise specified (NOS) OTHER MALIGNANT NEOPLASMS: ( specify) EPITHELIAL CELL ABNORMALITIES

6. cannot exclude HSIL ( ASC-H ) Atypical squamous cells

7. http://nih.techriver.net/patientImagesHighRes/6322.jpg?content-type=download ASC-H Source:

8. http://nih.techriver.net/patientImagesHighRes/5568.jpg?content-type=download Normal vs ASC-H Source:

10. http://nih.techriver.net/patientImagesHighRes/5866.jpg?content-type=download ASC-H Source:

12. http://nih.techriver.net/patientImagesHighRes/2064.jpg?content-type=download ASC-H vs HSIL Source:

14. The literature correlating different cytomorphological patterns with biopsy results ??

15. 1. MGH-like 2. Repair like 3A. Atrophy-like- with single cells 3B. Atrophy-like- with HCG of parabasal cell groups 4. ASC-H: NOS 5. Cyanophilic small atypical parakeratotic cells 6A. HSIL- syncytial 6B. HSIL- Single cell Cytomorphological Patterns of ASC-H.

17. - Cohesive clusters - Prominent nucleoli. - Low N/C ratio 2. “School of fish” Repair – like pattern Source: Chivukula M , Shidham V . CytoJournal 2006, 3:14

18. - Abundant blue cytoplasm - Open chromatin - W/wout nucleoli 3A. Atrophic “ Single-cell” pattern Source: Chivukula M , Shidham V . CytoJournal 2006, 3:14

19. - HCG of parabasal cells - Small dark nuclei - Variable, usually scant cytoplasm 3B. Atrophic “ Parabasal cell groups” Source: Chivukula M , Shidham V . CytoJournal 2006, 3:14

20. - HCG of small parakeratotic cells - Sharp angulated cell margins (vs round peripheral borders of cells at periphery of HSIL syncytium) - Small koilocytes - Relatively high N/C ratio - Chromatin may be smudgy 5. Small Atypical parakeratotic cells Source: Chivukula M , Shidham V . CytoJournal 2006, 3:14

23. Chivukula M, Shidham VB. ASC-H in Pap test- definitive categorization of cytomorphological spectrum. CytoJournal 2006, 3:14 doi:10.1186/1742-6413-3-14 Free full text is available at: http://www.cytojournal.com/content/3/1/14 PDF at: http://www.cytojournal.com/content/pdf/1742-6413-3-14.pdf

24. Cytomorphological Patterns associated with different clinicopathological categories. Source: Chivukula M , Shidham V . CytoJournal 2006, 3:14

25. Groups of metaplastic cells arranged in checkerboard like pattern . The dark nuclei may show nucleoli (arrows). (A & b- Cervical smear [Papanicolaou stained SurePath™ Preparation], c- Cervical biopsy [Hematoxylin-eosin stained section]). 1. MGH-like pattern Source: Chivukula M , Shidham V . CytoJournal 2006, 3:14

26. Shidham VB, Rao RN, Machhi J, Chavan A. Microglandular Hyperplasia has a cytomorphological spectrum overlappping with Atypical Squamous Cells- cannot exclude High-grade Squamous Intraepithelial Lesion (ASC-H). Diagnostic Cytopathology 2004 ;30:57-61.

27. Shidham et al. Diagnostic Cytopathology 2004 ;30:57-61.

28. Cohesive groups of cells with ill-defined school of fish pattern with relatively polarized cells with pointed ends (arrow head) show relatively low N/C ratio. The nuclei show nucleoli (arrows). (a & b- Cervical smear [Papanicolaou stained SurePath™ Preparation], c- Cervical biopsy [Hematoxylin-eosin stained section]). 2. Repair-like pattern Source: Chivukula M , Shidham V . CytoJournal 2006, 3:14

29. 3A. Atrophy-like pattern Single cell pattern. Isolated cells with hyperchromatic atypical nuclei with smudgy chromatin). (a & b- Cervical smear [Papanicolaou stained SurePath™ Preparation]). Source: Chivukula M , Shidham V . CytoJournal 2006, 3:14

30. Cohesive hyperchromatic crowded groups of small parabasal cells with high N/C ratio. The nuclei are relatively small and show nucleoli (arrow). (a & b- Cervical smear [Papanicolaou stained SurePath™ Preparation], c- Cervical biopsy [Hematoxylin-eosin stained section]). 3B. Atrophy-like pattern- HCG 0f Parabasal cell groups Source: Chivukula M , Shidham V . CytoJournal 2006, 3:14

31. Cohesive groups of atypical cells with mostly ill-defined cell borders . The nuclei vary in size with coarse chromatin; however, the nuclear details in most are relatively smudgy (arrows). (a & b- Cervical smear [Papanicolaou stained Sure-Path™ Preparation], c- Cervical biopsy [Hematoxylin-eosin stained section]). 4. ASC-H: NOS. Source: Chivukula M , Shidham V . CytoJournal 2006, 3:14

32. Cohesive groups of hyperchromatic cyanophilic small atypical parakeratotic (SAPK) cells with ill-defined cell borders, which are straight with angulations better seen at periphery. N/C ratio is higher. Chromatin is smudgy. Some cells may show koilocytic space around nuclei. (a & b- Cervical smear [Papanicolaou stained SurePath™ Preparation], c- Cervical biopsy [Hematoxylin-eosin stained section]). 5. Cyanophilic Small Atypical parakeratototic cells Source: Chivukula M , Shidham V . CytoJournal 2006, 3:14

33. Hyperchromatic crowded groups of cells without distinct cell borders. The hyperchromatic nuclei vary in size and show coarsely granular chromatin (arrows). (a & b- Cervical smear [Papanicolaou stained SurePath™ Preparation], c- Cervical biopsy [Hematoxylin-eosin stained section]). 6A. HSIL pattern)- Syncytial pattern. Source: Chivukula M , Shidham V . CytoJournal 2006, 3:14

34. 6B. HSIL pattern- Singly scattered (so called 'litigation') cells. Scattered, isolated, atypical cells show high N/C ratio. The nuclei have coarse chromatin without nucleoli (arrows). (a & b- Cervical smear [Papanicolaou stained SurePath™ Preparation], c- Cervical biopsy [Hematoxylin-eosin stained section]). Source: Chivukula M , Shidham V . CytoJournal 2006, 3:14

35. Reactive 1. MGH-like 2. Repair like 3A. Atrophy like- with single cells 3B. Atrophy like- with HCG of parabasal cell groups Indeterminate 4. ASC-H: NOS LSIL 5. Cyanophilic small atypical parakeratotic cells HSIL 6A. HSIL- syncytial 6B. HSIL- Single-cell Cytomorphological Patterns of ASC-H.

36. In summary, our study identified a cytomorphologic spectrum related with ASC-H interpretations , which demonstrated an association pattern with the results of biopsy and HPV test.

38. Other Twilight Zone- Some unequivocal cases of LSIL may also be associated some atypical cells suspicious for HSIL . How to evaluate them and how to report them? A dilema!!!!!

39. Shidham VB, Kumar N, Narayan R, Brotzman GL. Should LSIL with ASC-H (LSIL-H) in cervical smears be an independent category? A study on SurePath TM specimens with review of literature. CytoJournal 2007,4:7 Free full text is available at: http://www.cytojournal.com/content/4/1/7 PDF at: http://www.cytojournal.com/content/pdf/1742-6413-4-7.pdf

40. Cervical smear with unequivocal LSIL in other fields. This field shows rare LSIL (a & c) with some groups of cells consistent with ASC-H. The cells have a high N/C ratio with rounder curving cell borders (better seen in 'b'). At 20X (a), the ASC-H cell is difficult to focus because of three dimensional component in liquid based cytology. (a through c- Papanicolaou stained SurePathTM preps) LSIL-H (with CIN2 & HPV in biopsy) Source: Chivukula M , Shidham V . CytoJournal 2006, 3:14

41. Cervical smear (a, b) showed unequivocal LSIL cells in other fields. This field shows rare LSIL (a & b) along with some groups of cells consistent with ASC-H. The biopsy (c) showed only human papilloma virus cytopathic effect. Small atypical parakeratotic (SAPK) cells with distinct and sharp angulated cell borders with tinge of cytoplasmic eosinophilia (arrowhead in b) (see also corresponding area in a) were interpreted as ASC-H component. (a & b- Papanicolaou stained SurePathTM preps, c- HE stained cervical biopsy section). LSIL-H (with only HPV in biopsy) Source: Chivukula M , Shidham V . CytoJournal 2006, 3:14

42. Biopsy results for LSIL, LSIL-H, ASC-H, and HSIL Source: Chivukula M , Shidham V . CytoJournal 2006, 3:14

43. Source: Chivukula M , Shidham V . CytoJournal 2006, 3:14 LSIL-H as category overlap with LSIL and ASC-H, but was distinct from HSIL.

44. Biopsy Keratinizing CIN 3

45. LSIL-H as interpretation category is not a unique biologic entity . But it correlates with increased risk of high grade dysplasia on biopsy. Biopsy results pattern was intermediate between LSIL and ASC-H, but distinct from HSIL . For optimal clinical management a separate group of LSIL-H is justified . Application of molecular events such as p16 may be useful in the future. Conclusions

46. Source: Chivukula M , Shidham V . CytoJournal 2006, 3:14 Suggested Management algorithm of Women with LSIL-H. § Diagnostic excisional procedure- Sampling of transformation zone and endocervical canal for histological evaluation with laser conization, cold-knife conization, loop electrosurgical excision (LEEP), and loop electrosurgical conization.

47. Thank you Milwaukee Art Museum [email_address] End