Fig. 6.1
Atypical endocervical cells, most likely from a reparative process (CP). Routine screen from a 39-year-old woman. Sheet of cells that demonstrate nuclear enlargement, increased nuclear to cytoplasmic (N/C) ratios, prominent, sometimes multiple nucleoli, and mitotic activity. Three-year follow-up showed NILM cytology
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Fig. 6.2
Atypical endocervical cells, not otherwise specified (NOS) (LBP, ThinPrep). Cluster of slightly crowded endocervical cells with some nuclear crowding and round to oval nuclei showing washed-out chromatin. Follow-up showed tubal metaplasia. The terminal bars and cilia were difficult to visualize in this case. The fine granularity of the chromatin pattern is an important feature of cases that are derived from tubal metaplasia
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Fig. 6.3
Atypical endocervical cells, most likely related to ionizing radiation therapy (CP). A 54-year-old woman, 4 months status post radiation therapy for cervical carcinoma. Sheet of glandular cells showing nuclear enlargement, marked variation in nuclear size, prominent nucleoli, and distinct cell borders. Follow-up showed NILM
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Fig. 6.4
Atypical endocervical cells, NOS (LBP, ThinPrep). Cluster of crowded endocervical cells with nuclear enlargement, overlap and some nuclear irregularity. An ill-defined rosette is present at 11 o’clock. Follow-up showed AIS and HSIL. The cells in this image represent the three to four clusters of atypical endocervical cells present on the slide that correlate with AIS in the tissue biopsy. The rest of the slide showed cells diagnostic of HSIL which are not shown in this image
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Fig. 6.5
Reactive glandular cells associated with IUD (LBP, SurePath). A 45-year-old woman with an intrauterine device (IUD). The presumed endocervical cells demonstrate nuclear enlargement, nucleoli, and cytoplasmic vacuolization, consistent with changes associated with presence of an IUD. In the absence of a clinical history of IUD, such changes may be reported as atypical glandular cells, NOS
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Fig. 6.6
Atypical endocervical cells, NOS (CP). Cluster of cells with crowding and overlapping of nuclei, nuclear enlargement, chromocenters, and small nucleoli. Follow-up biopsies showed high-grade squamous intraepithelial lesion (HSIL) with extension into endocervical glands
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Fig. 6.7
Atypical endocervical cells, NOS (LBP, ThinPrep). ThinPrep imager stained cluster of endocervical cells with dark nuclei and some focal feathering with minimal nuclear overlap which was initially interpreted as atypical endocervical cells, NOS. Follow-up was normal. In retrospect dark imager staining, mimicking hyperchromasia, resulted in the overinterpretation
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Fig. 6.8
Normal endocervical cell “brush effect” (LBP, SurePath). Pictured is one of many such groups present on this slide, resulting from vigorous sampling with an endocervical “broom” device. The endocervical cells show uniform, evenly distributed, finely granular chromatin, and well-defined cytoplasmic boundaries consistent with a benign etiology
6.3.3 Atypical Endocervical Cells, Favor Neoplastic (Figs. 6.9–6.11)
6.3.3.1 Definition
Cell morphology, either quantitatively or qualitatively, falls just short of an interpretation of endocervical adenocarcinoma in situ or invasive adenocarcinoma.
6.3.3.2 Criteria
Abnormal cells occur in sheets and strips with nuclear crowding, overlap, and/or pseudostratification (Figs. 6.9 and 6.10).
Rare cell groups with rosettes (gland formations) or feathering (Fig. 6.11).
Nuclei are enlarged and often elongated with some hyperchromasia.
Coarse chromatin with heterogeneity.
Occasional mitoses and/or apoptotic debris.
Nuclear to cytoplasmic ratios are increased.
Cell borders may be ill-defined.
Preparation-Specific Criteria
Liquid-Based Preparations:
Cell groups may be three-dimensional, very densely packed, with layers of cells obscuring central nuclear detail.
6.3.4 Explanatory Notes
Endocervical and endometrial glandular cells may show a variety of cellular changes associated with various benign processes in the endocervical canal and endometrium [5]. Many of these reactive changes are not specific for any particular disease entity, but are of significance as mimics of glandular neoplasia in cervical cytology [6]. Reactive endocervical cells are characterized by the presence of a honeycomb or sheetlike arrangement with abundant cytoplasm, well-defined cell borders, and minimal nuclear overlap. Some degree of pleomorphism of cell size and nuclear enlargement may be noted; however, the nuclei remain round or oval with smooth contours and finely granular and evenly distributed chromatin. Nucleoli may be prominent, and multinucleation can occur, especially in cases of repair and inflammation. Cytoplasmic mucin may be diminished, giving the cell cluster a more hyperchromatic appearance. This constellation of reactive changes should be considered as “negative for intraepithelial lesion or malignancy” and not included in the AGC category (see Figs. 2.4, 2.32, and 2.33) [1].
“Atypical endocervical cells” may be used for cases demonstrating some, but not all, of the criteria necessary for endocervical adenocarcinoma in situ (AIS) or invasive adenocarcinoma. These features may include nuclear enlargement, crowding, variation in size, hyperchromasia, chromatin heterogeneity, and/or evidence of proliferation. Some nonneoplastic processes that may show atypical cellular changes and lead to interpretive difficulty include lower uterine segment sampling, tubal metaplasia, repair, endocervical polyps, microglandular hyperplasia, Aria–Stella change, and effects of ionizing radiation [5, 7–10].
Vigorous sampling using an endocervical brush may transfer large hyperchromatic groups of intact normal endocervical cells to the slide, resulting in so-called brush artifact (see Fig. 6.8). Such hyperchromatic groups may cause concern due to the inability to visualize centrally placed cells. These groups should be carefully evaluated for nuclear and architectural features of glandular or squamous neoplasia before rendering an “atypical” interpretation.
Tubal metaplasia is usually categorized as “negative for intraepithelial lesion or malignancy” (NILM). However, it is also a significant pitfall in the interpretation of glandular changes [10]. Only when the findings are sufficiently atypical to raise concern for neoplasia should the interpretation “atypical endocervical cells” be used. The nuclei of cells from tubal metaplasia are often enlarged, hyperchromatic, and pseudostratified, resembling those features seen in endocervical adenocarcinoma in situ (AIS) (Figs. 6.12, 6.13, and 6.14). Although some architectural and cytologic features overlap with AIS, the nuclei in tubal metaplasia tend to be round or oval and display more finely granular, evenly dispersed chromatin. Feathered edges, rosette formation, and mitoses may be seen, but they are less common compared to classic AIS. The most helpful criterion is the presence of cilia or terminal bars that may require high-powered microscopic evaluation of cell clusters to be appreciated. Although the presence of rare ciliated abnormal cells has been described in glandular neoplasia, terminal bars and cilia are indicative of a benign origin in the vast majority of cases. In addition, intermixed goblet cells and slender “peg” cells may be identified in tubal metaplasia (see Figs. 6.14, 2.19, 2.20, and 2.21) (Table 6.1). However, it must be remembered that because tubal metaplasia is very common in the high endocervical canal and lower uterine segment, it may coexist with endocervical neoplasia, and hence its presence should not dissuade an atypical or neoplastic designation if other types of atypical cells are present in the same specimen.
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Table 6.1
Adenocarcinoma in situ/AGC and mimics
Cytologic criteria | AIS | HSIL | Repair | Tubal metaplasia | Directly sampled endometrium/endometriosis |
---|---|---|---|---|---|
Cellularity | Cellular | Usually cellular | Rare fragments | Rare event | Few groups/variable |
HCGs | Many | Can be many | Absent | Rare | Present/can be numerous |
Sheets/strips | Many with feathering/3D | Syncytia | Flat sheets | Absent/rare | Present, 3D |
Nuclear crowding/overlap | Present | Present | Absent | Present but mild | Present |
Perpendicular nuclear polarization | Present | Absent | Absent | Present | Can be present |
Hyperchromasia | Present | Present | Absent | Mild | Mild |
Nuclear shape | Oval/elongate | Round/irregular | Round | Oval/cigar shaped | Oval/cigar shaped |
Feathering | Present | Absent/focal | Absent | Rare | Absent/rare |
Strips | Present | Absent | Absent | Present | Present |
Rosettes | Present | Absent | Absent | Absent | May be present/gland openings/tubules |
Terminal bars/cilia | Absent | Absent | Absent | Present/diagnostic | Rare/may be present |
Spindled stroma | Absent | Absent | Absent | Absent | Present |
Mitosis/apoptosis | Present | May be seen | Rare | Rare | May be present |
p16 pattern | Block positive | Block positive | Negative | Patchy positive | Patchy, focal to rare glandular cells |
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Fig. 6.9
Atypical endocervical cells, favor neoplastic (CP). Routine screen from a 29-year-old woman. Sheet of crowded cells with increased N/C ratios and mitotic activity. Note feathering at the edges of the sheet. Follow-up showed endocervical AIS
![A34936_3_En_6_Fig10_HTML.jpg](https://i0.wp.com/basicmedicalkey.com/wp-content/uploads/2017/06/A34936_3_En_6_Fig10_HTML.jpg?w=960)
Fig. 6.10
Atypical endocervical cells, favor neoplastic (CP). Pseudostratified strip of endocervical cells with enlarged, elongated nuclei and evenly distributed chromatin granularity
![A34936_3_En_6_Fig11_HTML.jpg](https://i0.wp.com/basicmedicalkey.com/wp-content/uploads/2017/06/A34936_3_En_6_Fig11_HTML.jpg?w=960)
Fig. 6.11
Atypical endocervical cells, favor neoplastic (LBP, ThinPrep). Atypical endocervical cells characterized by round or oval nuclei with nuclear enlargement, crowding, disordered arrangement, and occasional nucleoli. A rosette-like cellular arrangement is present. Follow-up showed endocervical AIS
6.3.5 Mimics of Atypical Glandular Cells (Fig. 6.12–6.14)
6.3.5.1 High-Grade Squamous Intraepithelial Lesion (Figs. 5.15–5.17, 5.25, 5.29, 5.31, 5.33, and 5.34)
HSIL involving gland spaces may present as contoured clusters mimicking the appearance of a glandular lesion (see Fig. 6.6). Groups are composed of tightly packed cells with high nuclear to cytoplasmic ratios and hyperchromatic nuclei with coarsely granular chromatin. In addition to classic morphologic descriptions, HSIL involving endocervical glands may also show the presence of nucleoli. The cytoplasm often has no specific differentiation. Flattening of cells at the periphery of the cluster, loss of cell polarity within the clusters, and the presence of isolated dysplastic squamous cells in the background can be very helpful features to suggest HSIL (see Figs. 5.15, 5.16, 5.17, 5.25, 5.29, 5.31, 5.33, and 5.34). HSIL involving gland spaces also lacks specific architectural features of AIS such as feathering, rosettes, and pseudostratified strips of columnar cells. Endocervical gland involvement by HSIL can lead to maintenance of cellular polarity within groups—a feature more commonly noted in glandular lesions and not characteristically present in the classic presentation of HSIL (see Table 6.1 and Figs. 6.23, 6.24, 6.26) [5, 11–13].
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Fig. 6.12
Atypical endocervical cells, most likely associated with tubal metaplasia (CP). Routine screen from a 38-year-old woman. Sheet of cells having enlarged, variably sized nuclei with some nuclear crowding and overlap. Note cilia at upper edge of sheet. Follow-up biopsy showed only tubal metaplasia
![A34936_3_En_6_Fig13_HTML.gif](https://i0.wp.com/basicmedicalkey.com/wp-content/uploads/2017/06/A34936_3_En_6_Fig13_HTML.gif?w=960)
Fig. 6.13
Tubal metaplasia. (a) Tubal metaplasia showing pseudostratified nuclei in a cellular strip (LBP, ThinPrep). Note the prominent terminal bars and cilia on the cells. (b) p16 immunostaining of tubal metaplasia (biopsy H&E) can show some positivity of the cells; however, not all cells in the epithelium are stained, in contrast to the diffuse staining typically noted in AIS (see Fig. 6.20)
![A34936_3_En_6_Fig14_HTML.jpg](https://i0.wp.com/basicmedicalkey.com/wp-content/uploads/2017/06/A34936_3_En_6_Fig14_HTML.jpg?w=960)
Fig. 6.14
Atypical endocervical cells, probably derived from tubal metaplasia (CP). Cell groups from tubal metaplasia may raise the differential diagnosis of endocervical adenocarcinoma in situ (AIS). It is useful to note that due to the presence of mucin in goblet cells overlying some nuclei, and the variety of cell types (goblet, ciliated, and peg) in tubal metaplasia, scattered nuclei demonstrate relative hypochromasia or a “washed-out” appearance and lack the monotony of changes characteristic of AIS (contrast with Fig. 6.21)
6.4 Atypical Endometrial Cells (Figs. 6.15–6.18)
6.4.1 Definition
The distinction of cytologically benign from atypical endometrial cells is based primarily on the criterion of increased nuclear size.
Atypical endometrial cells are generally not further qualified as favor neoplastic since this is a difficult and poorly reproducible distinction. However, specific comments can be appended if clinical findings/history is available (e.g., presence of IUD, polyp) [1].
6.4.2 Criteria
6.4.2.1 Preparation-Specific Criteria
Liquid-Based Preparations:
Nuclear hyperchromasia may be more prominent.
Nucleoli may be more prominent.
6.4.3 Explanatory Notes
Atypical endometrial cells, like their cytologically bland counterparts, may be associated with the presence of endometrial polyps, chronic endometritis, an intrauterine device (IUD), endometrial hyperplasia, or endometrial carcinoma (see Fig. 6.16). Caution should be used in the interpretation of atypia in endometrial material on liquid-based preparations because shed/menstrual endometrial cells may show significantly greater pleomorphism of nuclear size and shape than is seen in conventional preparations (see Figs. 3.2 and 3.4). These changes are likely due to improved visualization of degenerating endometrial cells resulting from clearing of blood, inflammation, and debris in liquid-based preparations from menstrual specimens and should not be overinterpreted as “atypical.” Clinical information can also be helpful in correctly categorizing such cases [5, 14]. The presence of “exodus” type of arrangements and a background containing endometrial stromal cells can be helpful in this discrimination.
Endometrial/endocervical cells derived from post-trachelectomy specimens (Figs. 6.19 and see Figs. 2.7, 2.8, 2.9, 3.5) may elicit an atypical glandular cell interpretation, especially when the history is not known. Helpful features include the presence of tubular glandular structures closely associated with bipolar endometrial stromal cells. In the absence of stromal cells, the geometric shape of the glandular clusters without feathering along the periphery is a helpful feature which is appreciated on low magnification [15–17].
Residual liquid-based cytology specimens can be used to make cell blocks to help resolve the origin of atypical glandular cells, including mimics, such as menstrual or directly sampled endometrium, and tubal metaplasia. Hematoxylin and eosin-stained sections and immunocytochemical stains, such as p16, may clarify the nature of densely crowded cell groups [18–21] (Fig. 6.20).
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Fig. 6.15
Atypical endometrial cells (CP). An 82-year-old woman with postmenopausal bleeding. Three-dimensional groups of small cells with mildly hyperchromatic nuclei, small nucleoli, and occasionally vacuolated cytoplasm. (a) shows a very tight cluster, while (b) shows a more loosely aggregated group. Follow-up showed endometrial hyperplasia
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Fig. 6.16
Atypical endometrial cells (LBP, ThinPrep). Small groups of cells with slightly enlarged nuclei, small nucleoli, and vacuolated cytoplasm. (a) A 63-year-old woman. Follow-up showed endometrial adenocarcinoma grade 1. (b) A 55-year-old woman. Follow-up showed endometrial hyperplasia
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Fig. 6.17
Atypical endometrial cells (LBP, ThinPrep). A 63-year-old woman with postmenopausal bleeding. Aggregate of small cells with slightly enlarged round or oval nuclei, small nucleoli, and finely vacuolated cytoplasm. Follow-up showed endometrial adenocarcinoma grade 1
![A34936_3_En_6_Fig18_HTML.jpg](https://i0.wp.com/basicmedicalkey.com/wp-content/uploads/2017/06/A34936_3_En_6_Fig18_HTML.jpg?w=960)
Fig. 6.18
Atypical endometrial cells (LBP, ThinPrep). A 52-year-old woman on hormone replacement therapy. Three-dimensional grouping of small cells with crowded round or oval nuclei. Follow-up showed endometrial hyperplasia
![A34936_3_En_6_Fig19_HTML.jpg](https://i0.wp.com/basicmedicalkey.com/wp-content/uploads/2017/06/A34936_3_En_6_Fig19_HTML.jpg?w=960)
Fig. 6.19
Directly sampled tubular endometrial glands with adjacent stromal elements seen post trachelectomy (LBP, SurePath). The geometric/tubular shapes of the endometrial glands should clue one in to the possibility of directly sampled endometrium. The stromal fragments consist of spindled cells but may be separated from the glands in liquid-based preparations
![A34936_3_En_6_Fig20_HTML.gif](https://i0.wp.com/basicmedicalkey.com/wp-content/uploads/2017/06/A34936_3_En_6_Fig20_HTML.gif?w=960)
Fig. 6.20
Comparison between benign endometrial tissue and endocervical AIS stained with the p16 immunostain. (a) Shed endometrium (cell block H&E), (b) shed endometrium (cell block p16), (c) AIS (biopsy H&E), and (d) AIS (biopsy p16). p16 is diffusely positive in AIS and essentially negative in shed endometrium. Cell blocks of residual material from cytologic specimens can be useful for the application of biomarkers (Compare to Fig. 6.13 for p16 staining pattern in benign tubal metaplasia)
6.5 Management of AGC
The 2012 consensus guidelines from the American Society for Colposcopy and Cervical Pathology (ASCCP) include recommendations for the initial workup and subsequent management of women with glandular abnormalities based on the 2001 Bethesda terminology [22].
Initial management of all categories of AGC, except atypical endometrial cells is colposcopy with endocervical sampling. Women 35 years and older or at risk for endometrial neoplasia should also have endometrial sampling. Those with atypical endometrial cells should have endometrial and endocervical sampling; colposcopy may be deferred if endometrial pathology is identified. Subsequent management of AGC depends on the findings from the initial sampling and cytologic interpretation. Triage using repeat cytology is not an option for the AGC category as it is high risk, and may harbor significant squamous and glandular preinvasive and invasive disease. If invasive disease is not identified on initial evaluation, a diagnostic excisional procedure is recommended for women with a cytologic interpretation of atypical glandular or endocervical cells, favor neoplasia or endocervical adenocarcinoma in situ.
The 2012 ASCCP guidelines do not recommend hrHPV triage for initial presentations of AGC. Based on two recent large studies from the United States, 25 % of cases in the AGC category test positive for hrHPV [23–25]. The most prevalent hrHPV genotypes detected are 18/45, followed by 16 [26, 27]. Overall, HPV genotype 16 and/or 18 accounts for 20–53 % of all AGC that are positive for hrHPV [26–28]. Few studies have addressed hrHPV positivity among the subcategories of AGC. Overall, approximately 50 % of AGC cases that test positive for hrHPV are found to be associated with significant lesions (e.g., HSIL, AIS or endocervical adenocarcinoma), whereas less than 5 % of AGC cases, which are negative for hrHPV, are found to be associated with significant HPV-associated precancer/cancer diseases [22, 23, 29]. In summary, hrHPV-positive AGC is more likely to have cervical pathology, such as adenocarcinoma in situ, endocervical adenocarcinoma, squamous intraepithelial lesion, or squamous carcinoma. hrHPV-negative AGC is more likely to show cancer which is endometrial or extrauterine in origin, or a benign reactive condition such as an endocervical or endometrial polyp.
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