LBC (ThinPrep) increased sensitivity in the detection of glandular lesions Dr. Terrence Colgan

Clinical History Pap test. A 44-year old woman was referred for colposcopy and management of an abnormal Pap smear. The patient subsequently underwent a loop electro-excisional procedure (LEEP). Four months later she returned for a follow-up visit and this ThinPrep was taken. Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer So, how was the case signed out? Satisfactory for evaluation TZ present Atypical glandular cells of undetermined significance not otherwise specified. LBC (ThinPrep) increased sensitivity in the detection of glandular lesions "The ThinPrep Pap test was more sensitive in detecting endometrial adenocarcinomas (65.2% vs. 38.6%; P=0.01), and there was a trend for a higher sensitivity in detecting cervical adenocarcinomas (87.1% vs. 55.5%; P=0.108) Schorge et al. Cancer (Cytopath) 2002; 96: 338 – 43. "The predictive value of AGUS for a positive follow-up result was 22% in the TP group and 15% in the CP group."… i.e ↑'d specificity Hecht et al. Cancer (Cytopath) 2002; 96: 1 – LBC (ThinPrep) increased sensitivity in the detection of glandular lesions Sept. 2005, US/FDA accepted PMA Supplement Improved ability of ThinPrep to detect glandular disease as compared to the conventional smear More frequent biopsy confirmation of abnormal glandular findings Therefore, glandular abnormalities on a ThinPrep merits increased attention ASCCP 2001 AGC Management Guidelines* For all AGC, except atypical endometrial cells: Colposcopy with endocervical sampling, And endometrial sampling if the woman is > 35 years or abnormal bleeding. re-affirmed in Apr'06 ASCCP posting HPV testing: a role in the management of AGC? [1] HPV testing has a high sensitivity for both AIS and CIN, with A Positive Predictive Value (PPV) of 40 - 61%, probably better than repeat cytology Could avoid colposcopic referral BUT…. HPV testing: a role in the management of AGC? [2] The risk of HSIL & Cancer is much higher in AGC than ASC Women with AIS (&AGC favour neoplasia?) on cyto' should proceed to colposcopy regardless In the > 35 year old, endometrial sampling for non-HPV related disease is recommended Some adenoca are not HPV related Rare adenoca's have L1/L2 deletion & are not detected by current assays Does HPV Testing have a role in the management of AGC? [3] Is the role of HPV testing as an adjunctive test only? For example as an exit criterion after colposcopy and endocervical sampling +/- endometrial sampling? i.e. using its high NPV Case presented with a SIL lesion: unusual? Index Pap test history & presenting symptoms of biopsy proven AIS patients (n=100) Symptoms (known in 87 cases) None in 82% Bleeding, discharge, other in 18% Index Pap Test (known in 83 cases) AGC or AIS in 54% HSIL in 64% Both AGC and HSIL in 17% Hwang et al. J Lower Genital Tr Dis 2004; 8: 125 – 31. Take home message – Case 7 AGC remains an important cytodiagnosis LBC (ThinPrep) is more sensitive in the detection of glandular abnormalities than conventional smears The index Pap test for biopsy proven AIS is frequently SIL The management of women with AGC on Pap test continues to evolve BUT for all AGC, except atypical endometrial cells - colposcopy with endocervical sampling References: Cox JT. The Clinician's View – Role of HPV testing in the ASCCP Guidelines for the management of abnormal cervical cytology and cervical cancer precursors. Arch Pathol Lab Med 2003; 127: 950 – 958. Hecht JL, Sheets EE, Lee KR. Atypical glandular cells of undetermined significance in conventional cervical/vaginal smears and Thin-layer preparations. Cancer (Cytopathol) 2002; 96: 1 – 4. Hwang D, Lickrish GM, Chapman W, Colgan TJ. Long-term surveillance is required for all women treated for cervical adenocarcinoma-in-situ. J Lower Genital Tr Dis 2004; 8: 125 – 31. Irwin W, Evans S, Anderson W et al. The utility of HPV DNA triage in the management of cytological AGC. Am J Obstet Gynecol 2005; 193: 559 – 65. Krane JF, Lee KR, Sun D et al. Atypical glandular cells of undetermined significance. Outcome predictions based on human papillomavirus testing. Am J Clin Pathol 2004; 121: 87 – 92. Pirog EC, Kleter B, Olgac S et al. Prevalence of HPV DNA in different histological subtypes of cervical adenocarcinoma. Am J Pathol 2000; 157: 1055 – 62. Saqi A, Gupta PK, Erroll M et al. High-risk HPV DNA testing: a marker for atypical glandular cells. Diagn Cytopathol 2006; 34: 235 – 9. Schorge JO, Saboorian MH, Hynan L, Ashfaq R. ThinPrep detection of cervical and endometrial adenocarcinoma. Cancer (Cytopathol) 2002; 96: 338 – 343. Wright TC, Cox JT, Massad LS, et al. 2001 Consensus Guidelines for the management of women with cervical cytological abnormalities. JAMA 2002; 287: 2120 – 9.