Diagnostic Cytopathology

Gastric‐type adenocarcinoma of the uterine cervix presenting in urine cytology specimens: A case report and literature review

AbstractGastric‐type endocervical adenocarcinoma (GEA) is a rare type adenocarcinoma of the uterine cervix that is unrelated to human papillomavirus (HPV). GEA is difficult to diagnose due to its bland‐looking morphological characteristics and is therefore often underdiagnosed. Although abnormal cells may be seen on cervical cytology specimens, they are rarely diagnosed as malignant and are often classified as atypical glandular cells. As a result, GEA may be diagnosed at advanced stages, with cytology samples from other organs after it has already invaded adjacent organs. Here, we report a case of GEA diagnosed by both cytological and histological examinations of urinary bladder and uterine cervix, after being identified as a non‐urothelial malignancy on a urine cytology. We also review and summarize the differential diagnoses for non‐urothelial lesions, particularly for glandular lesions observed on urinary cytology specimens, as well as the cytological and histological characteristics of GEA.

A Study on the Impact of HPV Genotype Infection Patterns on the Occurrence of High‐Grade Squamous Intraepithelial Lesion

ABSTRACTObjectiveTo investigate the differential risk of high‐grade squamous intraepithelial lesion or worse (HSIL+) associated with single versus co‐infection patterns of high‐risk human papillomavirus (HR‐HPV) genotypes.MethodsIn this retrospective cohort study, 10,570 patients with abnormal ThinPrep cytology test results and/or HR‐HPV infection who underwent colposcopy‐guided cervical biopsy at Wuhan Children's Hospital (May 2021–May 2023) were enrolled. Histopathological diagnosis served as the gold standard. Multivariate logistic regression was used to analyze HSIL+ risk across HPV infection patterns, adjusting for age and viral load.ResultsSingle infections with HPV31, HPV33, or HPV58 demonstrate comparable positivity rates of HSIL+ to HPV16 monoinfection. After adjusting for confounders, logistic regression revealed that co‐infection of HPV16 with low‐risk HPV genotypes reduced the risk of progression to HSIL+ compared to HPV16 monoinfection (p < 0.05). Similarly, co‐infections involving HPV33 or HPV58 (regardless of high/low‐risk partners) were associated with lower HSIL+ risk (all p < 0.05). In contrast, HPV31 demonstrated consistent HSIL+ risk irrespective of co‐infection status.ConclusionHPV16, HPV31, HPV33, or HPV58 need equivalent clinical vigilance in screening and management protocols. Co‐infection with low‐risk HPV genotypes attenuates HSIL+ risk in HPV16‐infected individuals, and HPV33/58 co‐infections (with any genotype) exhibit protective effects. Our study suggests that HPV31‐associated risk might remain unaffected by co‐infection, suggesting genotype‐specific biological interactions. These findings highlight the importance of genotyping‐guided risk stratification in cervical cancer screening.

A Genetic Twist: Cytologic Evaluation of Pancreatic Adenocarcinoma and Steatohepatitic Hepatocellular Carcinoma in a Patient With a Rare POLE Mutation

ABSTRACTMutations in the DNA polymerase epsilon (POLE) gene are associated with an increased risk of various malignancies, including colorectal and other gastrointestinal, endometrial, ovarian, breast, and brain cancers. In extremely rare cases, POLE mutations have also been associated with pancreatic and hepatobiliary carcinomas. We present the case of an 87‐year‐old female with a complex medical history including multiple malignancies, who underwent endoscopic ultrasound‐guided fine‐needle aspirations of a pancreatic head mass and a liver lesion. Utilizing rapid on‐site evaluation (ROSE) and full cytologic workup, she was ultimately diagnosed with synchronous pancreatic adenocarcinoma and the steatohepatitic variant of hepatocellular carcinoma. Given her history of multiple malignancies, she underwent genetic testing, and a rare germline POLE mutation was discovered. This case expands the phenotypic spectrum of potential POLE‐associated syndromes and highlights the critical role of cytopathology in fine‐needle aspiration procedures for diagnosis and management of complex oncologic cases.

Diagnostic efficacy of ascites cell block for ovarian clear cell carcinoma

AbstractBackgroundAscites cytology is important for determining the stage and treatment methods for ovarian clear cell carcinoma (CCC) as defined by the 2014 International Federation of Obstetrics and Gynecology classification.MethodsPatients with CCC who underwent surgery at our hospital between January 2012 and December 2019 and who received cytodiagnosis of their ascites using Papanicolaou (Pap) and May–Grünwald–Giemsa (MGG) staining, and cell block methods were identified. The cell block technique was performed using hematoxylin‐eosin (H&E) staining and immunohistochemical staining for hepatocyte nuclear factor‐1β (HNF‐1β), estrogen receptor (ER), progesterone receptor (PR), and Wilms tumor‐1 (WT‐1). Cancer cells of CCC were defined as tumor cells that were positive for HNF‐1β and negative for ER, PR, and WT‐1. The diagnostic accuracy of ascites cytology using Pap and MGG staining and cell block methods was examined.ResultsBased on cytological data, our study included 17 patients: seven (41.1%) with malignant (MAL) ascites, eight (47.1%) with negative for malignancy (NFM), and two (11.8%) with atypia of undetermined significance (AUS) because of a few atypical cells based on Pap and MGG staining. Malignant cells diagnosed by cell blocks were detected in 7/7 patients with MAL ascites based on PAP and MGG staining, 2/8 (25.0%) patients with NFM, and 1/2 (50%) patients with AUS.ConclusionThese findings show that the cell block method combined with the immunohistochemical investigation may be useful for increasing the diagnostic accuracy of malignant cells in CCC.

Endometrial cytological findings for a mesonephric‐like endometrial adenocarcinoma: A case report

AbstractA mesonephric‐like endometrial adenocarcinoma (ML‐EAC) is very rare and has a worse prognosis than other endometrial carcinomas. We describe an ML‐EAC and report our endometrial cytological findings. A 76‐year‐old woman presented with irregular genital bleeding and a uterine mass. Endometrial cytology revealed atypical cylindrical or spindle‐shaped cells in the form of small aggregates or solitary cells. The cell aggregates exhibited irregularly stacked papillary structures, small glandular structures, and fenestrated structures. The atypical cells had a nucleus with fine‐granular chromatin and a granular cytoplasm, and nuclear grooves and intranuclear pseudo‐inclusions were present. Hyaline globules were observed in the glandular lumens and in the background. The presumptive histological type was an adenocarcinoma, but the cytological features were different from those of an endometrioid carcinoma. A histological examination of the endometrial biopsy revealed an adenocarcinoma, and a simple hysterectomy was performed. A grayish‐white elevated mass measuring 90 mm × 70 mm × 40 mm was observed on the uterine corpus in the hysterectomy specimen. Histologically, the tumor proliferated as complex tubular structures containing eosinophilic colloid‐like materials and trabecular structures. The tumor cells were diffuse and positive for GATA‐3 and partially positive for thyroid transcription factor‐1. Estrogen and progesterone receptors were negative. An ML‐EAC was diagnosed. The tumor was invasive and extended beyond one‐half of the muscle layer with a high degree of vascular invasion. In conclusion, we need to focus on the various shapes of the cell aggregate, nuclear grooves, and intranuclear pseudo‐inclusions of tumor cells to distinguish an ML‐EAC from other endometrial carcinomas in endometrial cytology.

Comparison of glass and digital slides for cervical cytopathology screening and interpretation

The meaning of high‐risk HPV other than type 16/18 in women with negative cytology: Is it really safe to wait for 1 year?

AbstractBackgroundHuman papillomavirus (HPV) is a primary risk factor for cervical cancer. HPV 16 and 18 are the two most carcinogenic genotypes and have been reported in the majority of cervical cancer. High‐risk HPVs (hrHPVs) other than HPV 16/18 cause approximately a quarter of cervical cancers. We aimed to present the colposcopy‐guided biopsy results of non‐16/18 hrHPV‐infected women with negative cytology.MethodsThis is a retrospective cohort study conducted on 752 patients between the ages of 30‐65 years with non‐16/18 hrHPV and negative cytology undergoing colposcopy‐guided biopsy at a tertiary gynecological cancer center between January‐2016 and January‐2019.ResultsThe mean age of the women was 42.35±9.41 years. Cervical intraepithelial neoplasia (CIN) 2+ lesion was detected in 49 (6.5%) women with negative cytology. The rate of CIN 2+ lesions in women with abnormal cytology was 12.8%. Patients with abnormal cytology had about 2.1 and 2.4 times increased the odds of CIN 2+ lesion in cervical biopsy and endocervical curettage specimens, respectively. CIN 3+ lesion was detected in 20 (2.7%) women with negative cytology. One (0.1%) of the patients with HPV 39 and negative cytology had invasive cervical cancer. The two most common HPV subtypes were HPV 31 and HPV 51.ConclusionsThe risk of cervical preinvasive lesions still can be detected and cannot be completely eliminated among hrHPV other than 16/18‐infected women with negative cytology. Based on the results of this study, referral of non‐16/18 hrHPV‐infected women with negative cytology to colposcopy is supported as a credible and feasible strategy.

The Effect of Uterine Manipulator on Peritoneal Cytology Positivity in Endometrial Cancer: A Prospective Observational Study

ABSTRACTAimThere are studies suggesting that the use of a uterine manipulator during minimally invasive surgery (MIS) may lead to tumor spread in endometrial cancer patients, and there is no clear consensus on the safety of uterine manipulator use. The aim of this study was to investigate the effect of uterine manipulator use on peritoneal cytology (PC) results obtained before and after hysterectomy in endometrial cancer patients.MethodsA single‐center, prospective observational study was conducted, including 108 patients who were diagnosed with endometrial cancer and underwent surgical intervention. The patients were divided into three groups: Group 1 (n = 36), total abdominal hysterectomy (TAH); Group 2 (n = 41) laparoscopic hysterectomy with intrauterine manipulator (TLH with IUM); and Group 3 (n = 31) laparoscopic hysterectomy without IUM (TLH without IUM). PC samples were taken before and after the hysterectomy, and cytology results were compared among the groups.ResultsOf the 108 patients included in the study, 33.3% (36/108) were in Group 1, 38% (41/108) were in Group 2, and 28.7% (31/108) were in Group 3. The clinical and demographic data among the groups were similar (p > 0.05). PC was positive in six of the 108 patients. In the TLH with IUM group, one patient with a negative cytology sample before the manipulation showed a positive result after the hysterectomy.ConclusionsAlthough statistical significance was not reached, utilizing an IUM to manage endometrial cancer with MIS may enhance cytology positivity. This finding requires further validation through larger prospective studies.

“Atypical Glandular Cells” on Cervical Cytology: Correlation Between Glandular Cell Component Volume and Histological Follow‐Up

ABSTRACT Background Atypical glandular cells (AGC) in cervical cytology, as defined by the Bethesda System, indicate nuclear atypia beyond reactive changes but without definitive features of malignancy. Although clinically significant because it prompts follow‐up procedures, no quantitative threshold exists for AGC diagnosis. This study evaluated whether the volume of glandular cell clusters (GCC), regardless of atypia, influences AGC interpretation and may contribute to unnecessary sampling. Methods Following IRB approval, all cervical cytology cases diagnosed as AGC between January 2014 and June 2024 were retrieved, along with 100 random negative for intraepithelial lesion or malignancy (NILM) cases, and were manually re‐screened with quantification of glandular cell clusters (GCC) defined as a group of ≥ 6 cohesive glandular cells irrespective of origin (endocervical versus endometrial) and the results were correlated with follow‐up findings including endocervical and endometrial sampling. Results Of 301 AGC cases, 186 cases had slides available for review and follow‐up data; two were excluded due to unsatisfactory quality. Eight cases were reclassified as unsatisfactory because of insufficient squamous cells and absence of atypia, most of which exhibited high GCC (mean 59). Notably, 140 cases (76.6%) showed no significant glandular pathology on follow‐up, and in 111 cases (60.6%) the follow‐up was negative. Overall, increased GCC correlated significantly with AGC interpretation compared to NILM cases ( p  = 0.01), even when histologic follow‐up was negative. Conclusion Higher GCC volumes may influence AGC diagnoses, even in cases lacking true cytologic atypia, potentially leading to unnecessary interventions. Greater awareness of this tendency and adherence to established cytologic criteria may improve diagnostic precision within the AGC category.

Poor Performance of Applicator Tampon‐Based Self‐Collection for Liquid‐Based Cytology Among Women Attending a Tertiary Hospital in South Africa

ABSTRACT Background The South African Cervical Cancer Prevention and Control Policy was updated in June 2017, recommending liquid‐based cytology (LBC) as the preferred screening method and the investigation of self‐sampling for cervical cancer screening. Aim To compare the performance of the Self Collection Cervical Health Screening Kit [SelfCerv (applicator tampon)] to the Cervex‐Brush Combi for cytology screening. The study further aimed to compare high‐risk (hr‐) human papillomavirus (HPV) and LBC test results from both methods. Methods The study included 446 paired samples, comprising self‐collected (SelfCerv) and healthcare provider‐collected (Cervex‐Brush Combi) samples from women aged ≥ 18 years attending gynaecology outpatient clinics at a tertiary hospital in Pretoria, South Africa. LBC slides were prepared using the ThinPrep 5000 processor and manually stained with Hematoxylin and Eosin (H&E). Detection of 14 hr‐HPV types was performed using the Abbott RealTime HR‐HPV assay. Statistical analyses were performed using STATA version 17.0 (Stata Corp., College Station, Texas, USA). Results A statistically significant difference in cervical cytology detection between the two methods was observed ( p  = 0.0025). The Cervex‐Brush Combi was more effective in collecting endocervical cells (73.4%; 95% CI: 69.0–77.9) compared to the SelfCerv applicator tampon (7.3%; 95% CI: 4.7–9.9); ( p  < 0.001). Cytological abnormalities were detected in 65.4% (136/208) of participants who tested positive for hr‐HPV by healthcare provider sampling compared to 40.8% (84/206) by self‐sampling. A fair agreement ( κ : 0.35) with a concordance rate of 96.2% (95% CI: 94.4–98.0) was observed for specimen adequacy and diagnosis parameters [ κ : 0.34, with a concordance rate of 67.7% (95% CI: 63.2–72.1)] between the two methods. Conclusion The findings of this study do not support the implementation of applicator tampon‐based self‐collection as a method for cytology‐based cervical cancer screening.

The Value of P16 Protein Detection in the Screening for High‐Grade Squamous Intraepithelial and Higher Lesions of the Cervix by the Combined Detection of HR‐HPV and TCT

ABSTRACTLiquid‐based thin layer cytology (TCT) and HR‐HPV detection are the most important screening methods for cervical cancer. These two methods have limited sensitivity and specificity, so some cervical lesions are still missed or misdiagnosed. This paper mainly discusses the value of P16 protein detection in cervical cancer screening. In particular, it is effective and practical in high‐grade squamous epithelial and above cervical lesions (CINII+). In this retrospective study, the diagnostic specificity and positive predictive value (PPV) of P16 protein detection for cervical CINII+ lesions were significantly higher than that of TCT and HR‐HPV detection, and the accuracy was the highest. P16 protein detection can also reduce the rate of missed diagnoses in HR‐HPV‐negative patients and reduce unnecessary colposcopic biopsies. Our data highlight the feasibility and significance of P16 protein detection in cervical disease screening.

Sensitivity, Specificity, and Cost–Benefit Effect Between Primary Human Papillomavirus Testing, Primary Liquid‐Based Cytology, and Co‐Testing Algorithms for Cervical Lesions

ABSTRACTBackgroundCytology has long been a major screening method for cervical cancer prevention. Human papillomavirus (HPV) testing has recently been introduced for cervical cancer screening, and HPV tests become a major screening method in some countries. To seek the optimal strategy considering the cost‐effectiveness for cervical cancer screening, we compared the performance of primary LBC, primary HPV test, and LBC plus HPV co‐test in real practice.MethodsFrom March 2016 to June 2018, 3742 patients were included in this study. Liquid‐based cytology (LBC), HPV test, and histopathological assessment were performed in 3727, 1063, and 508 cases, respectively. The sensitivity, specificity, and cost–benefit effects of primary HPV, primary LBC, and co‐test algorithms were simulated for 317 cases with LBC, HPV, and histopathological results.ResultsOn the LBC, 13.0% of the cases were diagnosed with atypical squamous cells of undetermined significance or higher grade lesions. In the HPV test, high‐risk HPV was found in 43.5%, and 11.9% was positive for HPV type 16 or 18. Among the three simulated algorithms, the co‐test demonstrated the best sensitivity (97.5%) and the lowest specificity (50.3%). The primary LBC demonstrated the best specificity (53.5%) and a slightly better sensitivity, compare with the primary HPV (95.1% vs. 93.8%). Using the primary LBC algorithm, 82.0% can be determined without additional HPV test, whereas 50.1% could be determined without additional LBC using the primary HPV algorithm.ConclusionsThe primary LBC algorithm for uterine cervical cancer (UCC) screening is comparable to the primary HPV algorithm and has the best cost–benefit effect among the three algorithms.

Cytologic presentation of ovarian large cell carcinoma with rhabdoid features detected on peritoneal washing. Report of one case with cyto‐histologic correlation and previously undescribed inactivating SMARCA‐4 mutations

AbstractThe SMARCA subgroup of genes belongs to the SWI1/SNF1 family, responsible for chromatin remodeling and repair within the nucleosome. The SMARCA4 gene is located on chromosome 19p13 and encodes the BRG1 (BRAhMA) protein. We report the cytological and histological findings in one case of large cell SMARCA4 deficient ovarian carcinoma with positive peritoneal washing in a 69‐year‐old woman. The neoplastic cells were present as singly lying or perivascular clusters and showed medium or large size, round to oval hyperchromatic nuclei, and scarce to moderate cytoplasms. Molecular pathology investigations performed on the ovarian surgical sample found two previously undescribed mutations in the SMARCA4 gene and additional mutations in the CTNNB1 (Beta Catenin gene) and in PIK3CA. To our knowledge, this case probably represents the third cytologic report of this variant of ovarian carcinoma and the first one with molecular pathologic study.

Solitary cutaneous metastasis from an ovarian high‐grade serous carcinoma at the initial presentation: Cytologic diagnosis of a rare manifestation

AbstractCutaneous metastasis can rarely be the first manifestation of visceral malignancies and is commonly seen in advanced‐stage malignancies. It is infrequently seen in patients with ovarian malignancies and may develop either late in the course of the disease or at the initial presentation. Such cases are often associated with poor prognosis, and a prompt, precise tissue diagnosis is essential for appropriate patient management and better clinical outcome. Herein, we present a case of cutaneous metastasis in a young woman with an undiagnosed abdominopelvic mass that was diagnosed as metastatic high‐grade serous carcinoma (HGSC) on fine‐needle aspiration cytology (FNAC) supplemented by immunocytochemistry (ICC) on the cell block. The index case documents a unique and rare metastatic presentation of ovarian HGSC, as non‐Sister Mary Joseph anterior abdominal wall nodule, at the initial presentation. Additionally, it highlights the utility of minimally‐invasive FNA combined with ICC in prompt and accurate preoperative diagnosis of an underlying ovarian malignancy.

A retrospective analysis of pleural effusion specimens based on the newly proposed International System for Reporting Serous Fluid Cytopathology

AbstractBackgroundRecently, the International System for Reporting Serous Fluid Cytopathology (TIS) has been established, with an aim to standardize reporting and guide clinical decision making.MethodsThe cytological and clinicopathological data of pleural effusions were retrieved from the pathology database and electronic medical records. All specimens were evaluated and reclassified in accordance with the TIS recommendations. Finally, the risk of malignancy (ROM) and performance parameters were measured.ResultsA total of 2454 pleural effusion specimens were included, among which 30 (1.2%), 1670 (68.1%), 151 (6.2%), 54 (2.2%) and 549 (22.4%) patients were classified into non‐diagnostic (ND), negative for malignancy (NFM), atypia of undetermined significance (AUS), suspicious for malignancy (SFM) and malignancy (MAL) groups, respectively. The most commonly diagnosed malignancies were lung cancer (48.4%), ovary cancer (10.2%), breast cancer (7.5%), and 21.3% unknown primary site (UPS). Among the 36 UPS patients, the most common site of origin was lung (36.1%), followed by ovary (13.9%) and breast (11.1%) via immunocytochemistry of cell block. The calculated ROM values were 26.7%, 12%, 62.3%, 77.8% and 100% for ND, NFM, AUS, SFM and MAL groups, respectively. When considering MAL as the only positive group, the diagnostic accuracy, sensitivity, specificity, positive and negative predictive values were determined to be 95.2%, 81.9%, 100%, 100% and 93.6%, respectively.ConclusionThe newly proposed TIS is an easy‐to‐master, user‐friendly, and standardized classification system, especially when applying on pleural effusions. An adequate serous sample, application of immunocytochemistry, review of cytomorphological data and past medical history could enhance the accuracy of cytological diagnosis.

Aneuploidy detection for diagnostic and prognostic use in premalignant and malignant lesions of the uterine cervix: A systematic review

AbstractObjectiveTo systematically review the role of aneuploidy detection alone or in combination with other methods in cervical cancer screening and to evaluate the value of aneuploidy to predict the behavior of premalignant cervical lesions.MethodWe conducted a systematic review based on an electronic search for articles published between 2001 and 2020 across databases including MEDLINE/PubMed, Scopus, and Web of Science. Studies were subjected to data extraction, risk of bias, and narrative synthesis.ResultsA total of 15 articles were included in the review. Eight out of 15 studies (53.3%) were judged to be at a high or unclear risk of bias. From the 15 included studies, the index test to detect aneuploidy was DNA image cytometry (DNA‐ICM) in 12 studies and DNA flow cytometry (DNA‐FCM) in three studies. Nine studies also evaluated the performance of cytology and/or human papillomavirus (HPV) tests. For DNA‐ICM, sensitivity to detect cervical intraepithelial neoplasia or worse (CIN2+) varied between 59.0% and 95.9% and specificity varied between 54.1% and 100%. For DNA‐FCM, sensitivity varied between 27.3% to 96.8% and specificity was 100%. For cytological evaluation, sensitivity varied between 25.0% and 70.4% and specificity varied between 70.6% and 99.9%. For HPV detection, sensitivity varied between 39.4% and 100% and specificity varied between 23.3% and 84.3%.ConclusionDNA ploidy along with atypical cells findings in cytology and/or HPV detection revealed great value to detect CIN2+ lesions and to predict which lesions are more likely to progress to cervical cancer.

Accuracy of imprint cytology and frozen section histology for intraoperative diagnosis of ovarian epithelial tumors: A comparative study and proposed algorithm

AbstractBackgroundAppropriate surgical treatment of epithelial ovarian tumors is reliant on intraoperative diagnosis. A retrospective study to compare the diagnostic accuracies of imprint cytology (IC) with frozen section histology (FSH) in these tumors was performed.MethodsAbout 78 cases of IC‐based and FSH‐based diagnoses against the final histopathologic diagnoses in terms of both histologic subtype (serous, mucinous, endometrioid, or clear cell tumor) and behavioral type (benign, borderline, or malignant) were compared. The cytomorphologic features of the tumor cells (nuclear atypia, papillary clusters, adenoma cells, and necrosis) in relation to behavioral types were also evaluated.ResultsWhile the diagnostic accuracy of IC and FSH were similar with respect to behavioral type (87% and 88%, respectively), the diagnostic accuracy of IC was superior to that of FSH with respect to histologic subtype (83% and 74%, respectively). Among histopathologically confirmed malignant tumors, the diagnostic accuracy of IC (62/64; 97%) was superior to that of FSH (58/64; 91%). The presence of necrosis and absence of adenoma cells were significantly more prevalent among malignant group than among borderline and benign groups (P < .01, for both).ConclusionSince the presence of necrosis and absence of adenoma cells around the carcinoma cells appear useful in distinguishing malignant and borderline tumors, it was proposed to include IC for further intraoperative assessment of any tumors initially diagnosed as a borderline tumor by FSH.

Malignant perivascular epithelioid tumor of the vagina: Report of a rare case with brief review of literature

AbstractPerivascular epithelioid cell tumors (PEComas) are rare mesenchymal tumors with immunohistochemical co‐expression of melanocytic and myoid markers. Vaginal PEComas have been described in only nine cases so far. We describe the case of a 65‐year‐old female with a large growth in the left lateral vaginal wall. Biopsy imprint smears showed dispersed tumor cells with anisonucleosis, multinucleation, and bizarre forms, suggestive of a malignant tumor. Histopathology, however, showed perivascular arrangement of clear epithelioid cells, focal necrosis, intracellular brown pigment in few cells, and mitotic activity at 2 to 3 per 50 high power fields. Immunohistochemical positivity for vimentin, HMB‐45, S‐100 protein, desmin, and MyoD1 assisted in rendering a final pathological diagnosis of malignant PEComa of the vagina. Further work‐up revealed metastatic deposits in liver and retroperitoneal lymph nodes. PEComa arising in vagina is an unusual phenomenon with the malignant variant being an extremely rare tumor. Awareness of the characteristic morphology and utilization of a panel of immunohistochemical stains are mandatory to be able to make a precise diagnosis and appropriate prognostication.

Mixed germ cell tumors metastasis to Ascitic fluid: Report of a case with immunocytochemical findings

Assessment of cytological features of glandular lesions of the cervix on conventional smear preparations—a comprehensive study from a tertiary care hospital

AbstractBackgroundAtypical glandular cells (AGC) as a diagnostic category in cervicovaginal cytology remains as a challenge to cytopathologists.AimsThe aim of the present study is to identify the cytological features helpful in categorizing AGC as reactive or neoplastic upon correlation with histology.Materials and MethodsThe study was a retrospective review of cervical smears, with histopathological follow up, reported as glandular lesions for a period of 9 years. The architectural and nuclear features studied were adapted from The Bethesda System (TBS) to stratify the lesions as AGC, AGC‐FN (atypical glandular cells favour neoplasia) and adenocarcinoma. The cytological categories were correlated with histology.ResultsA total of 89 cases of which 67 (AGC NOS = 34, AGC FN = 19, adenocarcinoma = 14) with histology were reviewed. Neoplastic lesions were encountered in 14 cases (34.6%). Of the cases diagnosed as AGC‐NOS, AGC‐FN and adenocarcinoma, 26.5%, 68.4% and 100% respectively were neoplastic on histopathology. Squamous lesions accounted for 14.9% of all the glandular lesions. Rosette or acinar formation and loss of polarity frequently observed in neoplastic lesions as compared to reactive changes (p = 0.0004, p = 0.001). Of the nuclear features, nuclear hyperchromasia or coarse clumping of chromatin along with nuclear membrane irregularity and nuclear pleomorphism was frequently associated with neoplastic lesions as compared to reactive conditions (p = 0.007, p = 0.001, p = 0.0002).ConclusionA diagnosis of AGC at cytology harbors significant number of malignant lesions when confirmed on biopsy. Architectural features complemented with nuclear characteristics helps in differentiating between reactive and neoplastic conditions. Hence stratifying glandular lesions at cytology according to TBS helps in the management.

The prevalence, genotype distribution of human papillomavirus and cervical cytology in Wenzhou, China: a retrospective research of 7391 cases

AbstractBackgroundHuman papillomavirus (HPV) infection is the main pathogen of precancerous transformation and finally progress to cervical cancer. It associated with cervical squamous and glandular lesions. However, the genotype distribution of HPV and the relationship between HPV infection and cervical disease are still remind unclear.Material and methodsA total of 7391 abnormal cervical cytology cases with detailed histological reports and HPV genotypes were collected. The prevalence of HPV infection in squamous epithelial lesions and glandular epithelial lesions were statistically analyzed.ResultAround 6958 cytological squamous epithelial lesions and 433 glandular epithelial lesions were enrolled. 79.72% of cytological squamous epithelial lesions and 26.56% of glandular epithelial lesions were HPV infected. The HPV infection rates in squamous cell carcinoma, cervical adenocarcinoma and endometrial adenocarcinoma were 66.67%, 54.17% and 19.72%, respectively. HVP16, 18 and 58 are the most common types in squamous and glandular epithelial lesions. Among the squamous epithelial lesions, women less than 25 years old had the highest HPV infection rate, and majority of multiple infections was found in women >55 years old. The total infection rate of HPV in glandular epithelial lesions was the highest in the 35 to 45 group. Multiple infections peaked in women around 55 years old.ConclusionThe prevalence of HPV infection is divergent in different types of cervical cancer. The HPV infections in cervical squamous epithelial lesions tended to be younger. HPV detection is one of the necessary tests for cervical disease screening and should be individualized in an age manner.

Good performance of p16/Ki‐67 dual‐stain cytology for detection and post‐treatment surveillance of high‐grade CIN/VAIN in a prospective, cross‐sectional study

AbstractBackgroundThe limited sensitivity of Papanicolaou (Pap) cytology and the low specificity of HPV testing in detecting cervical or vaginal lesions means that either precancers are missed or women without lesions are overtreated. To improve performance outcomes, p16/Ki‐67 dual‐stain cytology has been introduced as a useful biomarker.MethodsA prospective, cross‐sectional study was performed and included 599 patients. Clinical performance estimates of Pap cytology, HPV DNA assay, and p16/Ki‐67 dual‐stain cytology for the detection of CIN2+/VAIN2+ were determined and compared.ResultsThe sensitivity and specificity of p16/Ki‐67 dual‐stain cytology in detecting histology proven CIN2+/VAIN2+ was 91.6% and 95.0%, respectively, while that of Pap cytology was 42.1% and 95.2%, respectively, and that of HPV DNA testing was 100% and 41.6%, respectively. Among the three tests, the AUC of p16/Ki‐67 immunocytochemistry was the largest, both for detecting cervical lesions and vaginal lesions, at 0.932 and 0.966, respectively. Among women who were HPV 16/18 positive or 12‐other hrHPV positive and Pap positive (≥ASCUS), dual staining reduced the number of unnecessary colposcopy referrals from 274 to 181. Among the women who were 12‐other hrHPV positive and Pap negative, dual staining could prevent underdiagnosis in six patients with CIN2+/VAIN2+ when used as a triage marker. Dual staining also identified four women with high‐grade lesions detected by diagnostic conization but with negative colposcopy‐guided biopsy results.Conclusionp16/Ki‐67 dual staining may be a promising tool for predicting high‐grade cervical and vaginal lesions.

Liquid‐based cytology of amoebic cervicitis clinically mimicking cervical cancer

Concordance ofHPV, conventional smear, colposcopy, and conization results in cervical dysplasia

AbstractBackgroundCervical cancer screening algorithms are increasingly focused on Human Papillomavirus (HPV)‐based screening while the accuracy of using abnormal cytological findings to detect dysplastic lesions still remains important. This retrospective study correlated the results of conventional cervical cytology, colposcopy guided biopsy, and cold knife conization (CKC) procedures performed in a tertiary center.Materials and MethodsData from 9399 patients who underwent screening with conventional cervical cytology between 2010 and 2019 was obtained from the hospital registry. Abnormal cervical cytology and high‐risk HPV DNA genotypes were recorded and their colposcopic and CKC pathology was determined.ResultsTwo hundred and ninety two patients underwent colposcopy for abnormal cervical cytology and/or high‐risk HPV positivity. One hundred and twenty three patients were positive for High‐risk HPV. Abnormal cervical cytology was detected in 216 patients. The most common cytological anomaly was atypical squamous cells of undetermined significance (ASCUS) found in 9399 patients (1.39%). It was determined that conventional cytology had a sensitivity of 70.8% and a specificity of 62.2% for the detection of low‐grade lesions, while it had a sensitivity of 72.4% and a specificity of 86.0% for the detection of high‐grade lesions. CKC was applied to 68 patients who were diagnosed with high‐grade squamous intraepithelial lesions (HSIL) as a result of the colposcopy. As a result of CKC, a high‐grade lesion was detected in 73.5% of these patients.ConclusionConventional cervical cytology and colposcopy exhibited higher accuracy as the severity of lesions increased. Detection of HPV may prevent unnecessary surgical procedures, especially with ASCUS.

Is cervical cytology testing as a part of co‐test unnecessary for HPV 16/18‐infected women? A retrospective cohort study of 1647 women

AbstractBackgroundWe aimed to present the biopsy results of women with HPV 16/18 infection and investigate whether cytology is necessary as a part of routine cervical cancer screening in women with HPV 16/18.MethodsThis is a retrospective cohort study conducted on 1647 patients between the ages of 30 and 65 years with HPV 16/18 undergoing colposcopy‐guided biopsy at a tertiary gynecological cancer center between January‐2016 and January‐2019. We compared the preinvasive lesion rates and the invasive cervical cancer rates of women with HPV 16/18 between the negative and the abnormal cytology group.ResultsOf the 1647 women, 1105 (67.1%) had negative cytology and 542 (32.9%) had abnormal cytology. Among women with initial negative cytology, cervical intraepithelial neoplasia (CIN) 2+ lesion was detected in 205 (18.6%) women. The rate of CIN 2+ lesion in women with abnormal cytology was 28%. There was a significant difference between negative and abnormal cytology group in terms of CIN 2+ lesion rates (P < .001). Among women with initial negative cytology, invasive cervical cancer was detected in 6 (0.5%) women. The rate of invasive cervical cancer in women with abnormal cytology was 8 (1.5%). There was no significant difference between negative and abnormal cytology group in terms of invasive cervical cancer rates (P = .082).ConclusionsThe rate of cervical cancer among HPV 16/18‐infected women with negative cytology is similar to women with abnormal cytology. Based on the results of this study, Pap testing could be unnecessary in HPV 16/18‐infected women to diagnose invasive cervical cancer who will undergo colposcopy biopsy.

Clinical performance of the aptima HPV assay in 4196 women with positive high‐risk HPV and ASC‐US cytology: A large women hospital experience

AbstractBackgroundDespite Aptima assay as the latest US Food Drug Administration (FDA)‐approved high‐risk human papillomavirus (hrHPV) test has been implemented as an adjunct in cervical cancer screening for years, histological follow‐up data remain limited with respect to its performance in women with ASC‐US Pap tests and positive hrHPV results.MethodsCases with results of ASC‐US cytology and positive hrHPV by Aptima assay during the period 06/ 2015–02/2017 were retrieved from archived pathology reports. Immediate histological follow‐up results were analyzed within 6 months interval after cotesting.ResultsAmong 4196 women with ASC‐US Pap tests and positive hrHPV, 51.1% of them had the immediate histological follow‐up within 6 months. With positive Aptima hrHPV as the adjunct, 46.5% (95%CI 46.2–46.8) of ASC‐US women were found to have cervical intraepithelial neoplasia type 1 (CIN1); 8.8% (95%CI 8.1‐9.5) women were detected CIN2+ lesion including eight adenocarcinoma in‐situ (AIS)s. CIN2+ detection rates were highest in women under 25 (15.4%, n = 65), when comparison with different age cutoffs, younger age women had higher CIN2+ lesion detection rate than that in older group (P <.01).ConclusionThis is by far one of the largest retrospective studies to analyze the histological follow‐up results of ASC‐US women with positive hrHPV tested by Aptima hrHPV mRNA assay. The results indicated that younger women with ASC‐US and positive hrHPV testing have highest risk of developing high grade CIN lesions as compared to the older women. Lastly, with positive HPV as the adjunct, 55.3% (1186/2145) of ASC‐US women will result in the positive finding on histological follow‐up.

Preliminary report on monolayer preparation of cervical sample by indigenous technique

The apparition macrophage and Döderlein bacillus is negatively correlated in class I Papanicolaou smear: A morphological examination

AbstractBackgroundNonspecific vaginitis, also known as Bacterial vaginosis, unlike genital candidiasis and trichomoniasis, is caused by microbiome breakdown. Döderlein’s bacillus are gram‐positive bacillus that form a microbiome, reproduce in the female vagina after gaining sexual maturity, secrete lactic acid, and prevent the growth of other vaginitis‐causing bacteria. Clue cell are squamous epithelial cells with Gardnerella sp. attached to their cell surface. The presence of clue cell is one of the diagnostic criteria for nonspecific vaginitis. Additionally, although macrophages are reported to protect against candidal vaginitis, there are no reports of studies examining the association between macrophages and clue cell.Materials and MethodsAfter re‐staining 300 class I specimens by cervical cancer screening with Papanicolaou staining, the appearance of Döderlein’s bacillus, macrophages, and clue cell was observed.ResultAge group and appearance of Döderlein’s bacillus were negatively correlated. The rate of appearance of macrophages was positively correlated with the age group. In people aged 50 years or more, the appearance rate of clue cells was significantly lower in the macrophage appearance group than that in the non‐appearance group.ConclusionThis study suggested that macrophages, and not Döderlein’s bacillus, may play an important role in defense against nonspecific vaginitis.

Cytologic features of cervical clear cell carcinoma of the cervix: Report of a case with immunocytochemical findings

Discriminant analysis and interpretation of nuclear chromatin distribution and coarseness using gray‐level co‐occurrence matrix features for lobular endocervical glandular hyperplasia

AbstractBackgroundLobular endocervical glandular hyperplasia (LEGH) is a disease considered to be the origin of tumorigenesis of minimal deviation adenocarcinoma, which has characteristic expression in the gastric pyloric mucosa. It is difficult to diagnose by nuclear findings because of lower nuclear atypia. In this study, nuclei of endocervical (EC) and LEGH cells were digitized, and nuclear information was quantified from nuclear images and objectively evaluated using a computer. We examined whether it is possible to distinguish between EC and LEGH cells, which is difficult by human eyes.MethodsSignal intensity, morphological features, Otsu thresholding technique and gray‐level co‐occurrence matrix (GLCM) features were calculated from nuclei of EC and LEGH cells on cytology microscopic images. Then, discriminant analysis was performed using the significant difference test and linear support vector machine (LSVM).ResultsGLCM features in LEGH cells were higher than those in EC cells. The nuclei of LEGH cells had a higher frequency of signal value pairs with a larger signal value difference than that of EC cells. Therefore, LEGH cell nuclei are thought to have more chromatin granules, and the chromatin is coarse and granular. Moreover, in the LSVM discriminant analysis, the accuracy of GLCM calculated using these features was 85.4%.ConclusionIn this study, GLCM accurately demonstrated the nuclear chromatin distribution and coarseness. Discriminant analysis of EC and LEGH cells using GLCM features is useful.

Cytohistological correlation in patients with atypical glandular cells on Papanicolaou test in a Chilean population

AbstractThe standard screening test for detecting cervical lesions and cancers is a Papanicolaou (Pap) smear. While squamous cell abnormalities remain the most common positive Pap test result, cytologic findings of glandular cell abnormalities have become more frequent in recent decades. The 2014 Bethesda System for reporting cervical cytology includes the classification “atypical glandular cells” (AGC). AGC have morphological abnormalities that fall outside the range of reactive changes, but are insufficient for a diagnosis of invasive adenocarcinoma. In several histologic follow‐up studies, most AGC cases were found to represent a benign condition. In the current study, we evaluate the significance of AGC cytology findings by analyzing the histologic follow‐up results of a large number of patients with AGC. Most patients with AGC in this study were found to have a significant lesion on follow‐up (63.9%), with negative histologic results in only 36.1% of patients. Among patients with significant lesions, the most common result was low‐grade squamous intraepithelial lesion (26.6%), followed by high‐grade squamous intraepithelial lesion (23.2%). This provides further evidence to support the Chilean Clinical Guidelines for Cervical Cancer, which recommends diagnostic follow‐up studies in all women with AGC to minimize the chance of undetected serious cervical disease.

The reporting rates of high‐grade squamous intraepithelial lesions and their human papillomavirus testing and histologic follow‐up results: A comparison between ThinPrep and SurePath preparations

AbstractBackgroundLiquid‐based cytology (LBC) tests SurePath (SP) and ThinPrep (TP) have largely replaced conventional Papanicolaou (Pap) tests for cervical cytology screening due to higher sensitivity. However, comparison between SP and TP test sensitivity and efficacy in detecting squamous abnormalities is lacking. Our study aims to compare high‐grade squamous intraepithelial lesion (HSIL) reporting rates, human papillomavirus (HPV) positivity rates, and histologic outcome between these two LBC methods.Materials and MethodsWe performed a retrospective search of the period between January 2014 and June 2017, when both TP and SP were utilized at our institution, to identify HSIL cases and collect the HPV testing and histologic follow‐up results for those cases.ResultsOne hundred twenty‐five HSILs were identified from the 15 382 TP specimens (0.81%) and 93 HSILs were identified from the 25 105 SP specimens (0.37%), a statistically significant difference (P < .0001). The corresponding HPV positivity rates were 95.6% and 89.7% in TP‐HSILs and SP‐HSILs, respectively, a statistically non‐significant difference. Histologic follow‐up showed HSILs or carcinomas were identified in 78% (49/63) of TP‐HSILs and 79% (45/57) of SP‐HSILs, with no statistically significant difference.ConclusionTP demonstrated a higher HSIL detection rate than SP with no significant difference in follow‐up HPV or histologic results.

Hematoidin crystals in Pap smear: A revisit

Cervical cytology reproducibility and associated clinical and demographic factors

AbstractBackgroundAlthough the Pap test has been the standard screening method for cervical precancer/cancer detection, it has been criticized for having a relatively low sensitivity and a low reproducibility between pathologists. There is limited knowledge about inter‐rater agreement and what clinical and demographic factors are associated with disagreements between pathologists reading the same Pap smear.MethodsThis study aimed to assess inter‐ and intra‐ rater agreement of the Pap smear in 1619 cytologic slides with biopsy confirmation, using kappa statistics. Clinical and demographic factors associated with higher odds of inter‐rater agreement were also examined and stratified by histologic diagnosis grade.ResultsUsing a five grade classification system, the overall kappa statistics for total, inter‐rater, and intra‐rater samples were 0.62, 0.57, and 0.88 (unweighted) and 0.83, 0.81, and 0.95 (weighted), respectively. In stratified analyses by histologic grade, total kappas ranged from 0.40 (atypia) to 0.64 (human papilloma virus/CIN 1). Factors such as referral for abnormal Pap test (diagnostic vs screening population), recruiting site, and parity were found to be associated with higher agreement between the two cytologic readings.ConclusionsWe observed relatively higher levels of agreement compared with other studies. However, variability was considerable and agreement was generally moderate, suggesting that cervical screening test accuracy and reproducibility needs to be improved.

Metastatic Vulvar Paget's Disease Presenting in a Supraclavicular Lymph Node: A Diagnostic Challenge on Fine Needle Aspiration Cytology

ABSTRACT Background Extramammary Paget's disease (EMPD) of the vulva is a rare intraepithelial adenocarcinoma with a typically indolent course. Distant metastasis, particularly to supradiaphragmatic lymph nodes, is exceedingly uncommon and poses a significant diagnostic challenge. Case Presentation We report a rare case of metastatic vulvar EMPD presenting as a left supraclavicular lymph node enlargement in a 72‐year‐old woman with a known history of EMPD since 2014. Cytologic smears from the lymph node revealed large, discohesive epithelial cells with pale vacuolated cytoplasm and prominent nucleoli. The concurrent core biopsy demonstrated effacement of nodal architecture by similar cells forming loose clusters and abortive glandular structures. Immunohistochemistry showed tumor cells positive for CK7, CK20, GATA3, and TRPS‐1, with focal mammaglobin expression and negative staining for CDX2, PAX8, CK5/6, P40, and P63. Special stain with mucicarmine highlighted abundant intracytoplasmic mucin—a key morphologic clue favoring EMPD over a breast primary. Conclusion This case illustrates the diagnostic complexity of EMPD metastasizing to an unusual site and highlights the critical role of cytomorphology, special stains, and immunohistochemistry in excluding alternate primaries. Mucicarmine staining highlighted abundant intracytoplasmic mucin, serving as a useful adjunct in raising suspicion for EMPD. While not specific, in conjunction with cytomorphology and immunohistochemistry, this supported EMPD over invasive ductal carcinoma of the breast. Given the rarity of such distant nodal metastases, a high index of suspicion should be maintained for EMPD in patients with a known history, even when metastases appear in non‐regional lymph nodes.

Cytomorphometry and morphology analysis of human papillomavirus type 16 in liquid‐based cervical cytology samples

AbstractBackgroundHuman papillomavirus (HPV) is the main causal factor of cervical carcinoma. HPV 16 is one of the most prominent oncogenic types. We aimed to evaluate the cytomorphometric and morphological alterations caused by HPV 16 in liquid‐based cytology (LBC).MethodsThe Cobas 4800 HPV system was used for the detecting and typing HPV DNA in cervical specimens. In this study, 30 HPV 16 positive and 30 HPV 16 negative cervical samples were evaluated for micronuclei (MN), nonclassical cytologic abnormalities, and the nuclear‐to‐cytoplasmic ratio. Nuclear and cellular areas were evaluated using image analysis software and the nuclear‐to‐cytoplasm ratio was calculated. All analyses were performed blinded to the patients' HPV status. Statistical evaluation was carried out using the χ2 and Fisher test; P‐values < .05 were considered significant.ResultsThe frequencies of micronucleated cells and koilocytes were higher in the HPV 16 infected group (P < .05). Cells with perinuclear halo in control group were higher than the HPV 16 infected group (P < .05). The mean nuclear‐to‐cytoplasm ratio in HPV 16 patients was higher than the control value, but the difference was not statistically significant.ConclusionLBC can be used to detect morphological and morphometric changes. HPV 16 induces the formation of MN and koilocytosis. The evaluation of MN could provide additional information in monitoring genomic instability and of koilocytes could provide information about damage to the cytoskeleton filaments in HPV infection. Further studies are needed to investigate the effects of HPV‐18 and other high‐risk HPV types on the cell size and nucleus‐to‐cytoplasm ratio.

Causation of cornflake artifacts: Possible association of poor dehydration with drying before mounting in Papanicolaou stain

AbstractCornflake artifacts are artifacts that commonly occur while the mounted medium starts to evaporate before coverslipping. This study aimed to determine factors contributing to the occurrence of these artifacts in Papanicolaou (Pap) smears. Residual specimens were used after cytology to microscopically evaluate various effects on cornflake artifacts. Four SurePath™ liquid cytology (LBC) cell specimens, diagnosed as negative for intraepithelial lesions or malignancy (NILM), were used. Each LBC smear was subjected to Pap staining under four different conditions (A, without air‐drying; B, air‐drying after dehydration; C, air‐drying after xylene immersion; and D, air‐drying after dehydration and xylene immersion) using two methods: conventional and poor dehydration. Cornflake artifacts were not observed in A and B in Pap staining. By contrast, cornflake artifacts were observed in conventional and poor dehydration methods when dried after xylene immersion. When comparing the four conditions, smears B and D, which were both air‐dried after dehydration, had fewer cornflake artifacts than smear C, which was air‐dried only after xylene. Therefore, the remaining water in the cells due to poor dehydration during xylene immersion is found to result in the development of cornflake artifacts. The present study revealed that cornflake artifacts in Pap smears are caused by poor dehydration in addition to drying before mounting.

The importance of biomonitoring studies for detecting cytogenetic damage in cervical biopsy samples infected with human papillomavirus type 16

Application of the Bethesda system of reporting for cervical cytology to evaluate human papilloma virus induced changes in oral leukoplakia, oral squamous cell carcinoma, and oropharyngeal squamous cell carcinoma: A cytomorphological and genetic study

AbstractBackgroundHuman papilloma virus (HPV) has a well‐established carcinogenic role in certain head and neck cancers. These HPV associated cancers possess unique clinicopathological behavior and exhibits better prognosis than their negative counterparts. Detection through polymerase chain reaction (PCR) has been considered as the “gold standard” but imposes burden in low resource settings. Therefore, in the present study, we assessed the validity of cytomorphological features for the detection of HPV in oral leukoplakia (OL), oral squamous cell carcinoma (OSCC), and oropharyngeal squamous cell carcinoma (OPSCC).MethodologyThis study included 63 subjects comprising of 25 OL, 26 OSCC, and 12 OPSCC cases. Exfoliated cells were collected and processed for PCR followed by Papanicolaou staining and subsequent grading. Additionally the non‐classical signs were evaluated and statistical analysis included Chi‐square and Spearman's test.Result23/63 (36.5%) cases showed PCR positivity for HPV16. Most of the cytomorphological features showed significant correlation for the presence of HPV. A greater sensitivity and specificity was observed in the Bethesda system for reporting cervical cytology (TBS) than the Papanicolaou grading system.ConclusionWe conclude that the non‐classic cytological features could be employed in the detection of HPV in low resource settings with improved sensitivity. Liquid based cytology graded using TBS could be suitable for oral cytology in the detection of early atypical changes.

Cervical cancer: Automation of Pap test screening

AbstractBackgroundCervical cancer progresses slowly, increasing the chance of early detection of pre‐neoplastic lesions via Pap exam test and subsequently preventing deaths. However, the exam presents both false‐negatives and false‐positives results. Therefore, automatic methods (AMs) of reading the Pap test have been used to improve the quality control of the exam. We performed a literature review to evaluate the feasibility of implementing AMs in laboratories.MethodsThis work reviewed scientific publications regarding automated cytology from the last 15 years. The terms used were “Papanicolaou test” and “Automated cytology screening” in Portuguese, English, and Spanish, in the three scientific databases (SCIELO, PUBMED, MEDLINE).ResultsOf the resulting 787 articles, 34 were selected for a complete review, including three AMs: ThinPrep Imaging System, FocalPoint GS Imaging System and CytoProcessor. In total, 1 317 148 cytopathological slides were evaluated automatically, with 1 308 028 (99.3%) liquid‐based cytology slides and 9120 (0.7%) conventional cytology smears. The AM diagnostic performances were statistically equal to or better than those of the manual method. AM use increased the detection of cellular abnormalities and reduced false‐negatives. The average sample rejection rate was ≤3.5%.ConclusionAMs are relevant in quality control during the analytical phase of cervical cancer screening. This technology eliminates slide‐handling steps and reduces the sample space, allowing professionals to focus on diagnostic interpretation while maintaining high‐level care, which can reduce false‐negatives. Further studies with conventional cytology are needed. The use of AM is still not so widespread in cytopathology laboratories.

Diagnostic utility of ThinPrep Imaging System® for detecting atypical glandular cells in cervical smear samples

AbstractIntroductionThe ThinPrep Imaging System® (TIS) is an automated system that has now been used for over 20 years in the primary screening of ThinPrep liquid‐based cervical samples. Although there are a lot of publications about the diagnostic utility of this method in squamous cell lesions, which has advantages such as time‐saving and standardization, there are only a few publications on this issue in glandular cell lesions in the literature. We aimed in this study to investigate the diagnostic utility of the system in the detection of premalignant and malignant glandular lesions in cervical smears.Material and MethodOur study was conducted retrospectively, and a total of 126 cervical smear samples between 2010 and 2022 that have histological confirmation of endometrial adenocarcinoma (EAC), endocervical adenocarcinoma (ECAC), or adenocarcinoma in situ (AİS), were included. These samples were re‐evaluated by manual and TIS by two experienced pathologists, and the results were compared in terms of sensitivity.ResultsWe found out that 70 of the 126 smear samples have atypical glandular cells. We detect 48 cases (48/70) (sensitivity 68.5%) in manual examination, however TIS successfully determined 66 cases (66/70) (sensitivity 94.3%). In 4 cases (5.7%) TIS could not detect the atypical cells within the 22 areas.ConclusionTIS is quite an effective method with a high sensitivity for detecting atypical glandular cells in cervical smears, like detecting squamous cell anomalies. Imposing this system in our laboratory and using them appropriately, save us time and help to ensure standardization. Additionally, it may be a good way to adopt artificial intelligence and digital pathology in today's world.

Cervicovaginal cytology, HPV testing and vaginal flora in transmasculine persons receiving testosterone

AbstractBackgroundTestosterone is one of the strategies that transmasculine persons can elect in order to align physical traits to their gender identity. Previous studies have shown morphologic changes in the genital tract associated with testosterone. Here, we aim to evaluate cervicovaginal cytology specimens (Pap tests) and high‐risk HPV (HR‐HPV) testing from transmasculine individuals receiving testosterone.MethodsThis is a retrospective cohort of 61 transmasculine individuals receiving testosterone from 2013 to 2021. Cytologic diagnoses from 65 Pap tests were correlated with HPV status and histologic follow‐up and compared with the institutional data and a cohort of cisgender women with atrophic changes.ResultsThe median age was 28 years and median time of testosterone use was 3 years. Transmasculine persons showed significantly higher rates of HSIL (2%) and unsatisfactory (16%) when compared with the institutional data and atrophic cohort of cisgender women. After reviewing slides of 46 cases, additional findings were noted: atrophy was present in 87%, glycogenated cells were seen in 30%, and Lactobacilli were substantially decreased in 89%. Among 32 available HPV tests, 19% were positive for HR‐HPV and 81% were negative. On histologic follow‐up, all HR‐HPV‐positive cases with abnormal cytology showed HSIL, while none of the HPV‐negative cases revealed HSIL.ConclusionOur study cohort demonstrated a high percentage of abnormal Pap tests in transmasculine persons receiving testosterone. Testosterone seems to induce changes in squamous cells and shifts in vaginal flora. HR‐HPV testing can be a useful adjunct in the workup of abnormal Pap tests from transmasculine individuals.

Clinical value of the ThinPrep cytologic test with E6/E7 mRNA detection for cervical cancer screening in disease diagnosis

AbstractBACKGROUNDTo investigate the clinical value of the ThinPrep cytologic test (TCT) with the E6/E7 mRNA test for cervical cancer screening in disease diagnosis.METHODSA total of 405 samples from Dazhou Central Hospital from April 2017 to July 2020 were collected, and we conducted a comparative analysis of the diagnostic performance of several test methods both individually andcombination.RESULTSThe sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and area under the curve (AUC) were compared by single TCT, E6/E7 mRNA test, and combination methods. The TCT+E6/E7mRNA test was confirmed to have a relatively higher specificity of 80.32% (95% CI: 75.40%–84.48%, both P < 0.001), and AUC value (0.78, 95% CI: 0.73–0.83, and P < 0.001).CONCLUSIONThe relative diagnostic value may be further improved by the combined detection of TCT and E6/E7 mRNA test. The combined detection of TCT and the E6/E7 mRNA test is expected to become a potential indicator for cervical lesions.

The necessity of continuing cervical cancer screening of elderly Korean women aged 65 years or older

AbstractBackgroundAlthough the incidence of cervical cancer has decreased since the 1980s in Korea, it remains high among the elderly women. This study evaluated the suitability of cervical cancer screening for elderly Korean women aged ≥65 years according to recommendations by the American Society of Cytopathology and American Society for Colposcopy and Cervical Pathology.MethodsWe retrospectively reviewed the records of patients who underwent cervical cancer screening, followed by liquid‐based Pap test, human papillomavirus (HPV) test, and colposcopic punch biopsy at two academic hospitals from May 2008 to May 2018. The participants were divided into two groups <65 and ≥65 years old. Logistic regression analysis was performed to evaluate the association between cytology tests, HPV tests and the occurrence of high‐risk lesions, ≥cervical intraepithelial neoplasia2 (CIN2).ResultsThe mean patient age was 49.02 ± 15.437 (range 15–91) years. No patients aged <25 years showed atypical squamous cell‐cannot exclude high grade (ASC‐H), squamous cell carcinoma (SCC), or adenocarcinoma (ADC). The incidence of high‐grade squamous intraepithelial lesion (HISL) (39.7%) and ≥CIN 3 (40.2%) was significantly higher in patients ≥65 years of age than in other age groups. However, patients ≥65 years showed increased HSIL and HPV negativity and ASC‐H, HSIL, and HPV positivity in those with ≥CIN 2 (both p = .043).ConclusionKorean women aged ≥65 years should undergo cervical cancer screening. The relevance of HPV or Cytology test alone or co‐test for screening should be evaluated in this population.

Small‐cell neuroendocrine carcinoma of the cervix accompanied by adenocarcinoma and high‐grade squamous intraepithelial lesion

AbstractFew cytological reports have described small‐cell neuroendocrine carcinoma (SCNEC) in the female genital tract. In the present study, we describe a cytological case of SCNEC accompanied by adenocarcinoma, as well as high‐grade squamous intraepithelial lesion (HSIL). A Japanese woman (42 years old) presented with abnormal genital bleeding. A conventional Papanicolaou smear revealed an inflammatory condition with three neoplastic components: SCNEC as irregular aggregates of neoplastic small round cells with nuclear molding and granular chromatin; adenocarcinoma as columnar cell clusters with peripherally located large nuclei, and HSIL as sheets or clusters of dysplastic basal‐type squamous cells with irregular hyperchromatic nuclei. Accordingly, a cytodiagnosis of SCNEC with adenocarcinoma and HSIL was made. Owing to the rarity of cervical SCNEC, cytological diagnosis may be difficult. Due to its aggressive clinical behavior, the presence of an SCNEC component should be verified in any cytodiagnosis of adenocarcinoma or HSIL.

Re: “Cytomorphometry and morphology analysis of human papillomavirus type 16 in liquid‐based cervical cytology samples” by Safi Oz et al.

Endometrial Liquid‐Based Cytology Specimens Preserve High Genome Quality for Molecular Classification After Long‐Term Storage

ABSTRACTBackgroundMolecular classification of endometrial cancer is useful for predicting prognosis. Genomic examinations are performed using formalin‐fixed paraffin‐embedded (FFPE) tissues; however, we previously reported that liquid‐based cytology (LBC) specimens can be used for next‐generation sequencing (NGS). In this study, we evaluated long‐term storage effects of LBC specimens on NGS‐based genomic profiling, including gene mutations, tumor mutation burden (TMB), and microsatellite instability (MSI).MethodsFour LBC fixatives (CellPrep, ThinPrep, CytoRich Red, and SurePath) were used to prepare NGS samples from cultured endometrioid carcinoma HEK‐251 cells. Twelve endometrial LBC specimens from patients with endometrioid carcinoma were fixed with CytoRich Red. The TMB, MSI, and gene mutations were analyzed after 1 week, 6 months, and 12 months of storage in cultured HEK‐251 cells. Paired LBC and FFPE specimens of endometrioid carcinoma stored for 15–45 months were subjected to NGS‐based analysis, and their molecular profiles were compared to those at the initial diagnosis.ResultsThe TMB and MSI did not differ during the storage periods for any of the LBC fixatives in the cultured cells; in addition to gene mutations, they were comparable between the initial and second analyses of the clinical FFPE and LBC specimens. There were no changes in the integrative diagnosis of the endometrioid carcinoma subtype classification.ConclusionLBC specimens, which preserved high‐quality genomes for molecular classification after long‐term storage, may be an alternative source of genomic examination for the integrative diagnosis of endometrial cancer.

Bilateral Cystic Endosalpingiosis in Cervical Lymph Nodes Mimicking Metastatic Papillary Thyroid Carcinoma Morphologically on Cytology: A Case Report and Literature Review of Diagnostic Challenges

ABSTRACTThe presence of cystic lymph nodes in the neck can present a challenging differential diagnosis, with considerations often including metastatic papillary thyroid carcinoma (PTC), cystic squamous cell carcinoma, and congenital cysts. The cytologic overlap between benign Müllerian inclusions and PTC features adds complexity, especially in unusual locations. A 45‐year‐old woman with a history of ovarian serous borderline tumor (SBT) and non‐invasive Müllerian implants presented with cystic lymphadenopathy in the neck. Imaging revealed multiple suspicious, partially cystic lymph nodes. Fine‐needle aspirations (FNA) from two nodes showed moderate cellularity, monolayered epithelial sheets, and nuclear features suggestive of PTC. FNA cytology, thyroglobulin level, and immunocytochemical profile revealed benign Müllerian cells within lymph nodes. Subsequent histologic evaluation of the excised lymph nodes confirmed cystic endosalpingiosis. This case emphasizes the value of comprehensive clinical‐pathologic correlation and appropriate ancillary studies in the evaluation of cystic lymphadenopathy. Awareness of benign Müllerian inclusions and their mimicry of metastatic disease is essential for accurate diagnosis and optimal patient management.

Expression of EGFR, PD‐L1, and the mismatch repair proteins before and following therapy in malignant serous effusions with metastatic high‐grade serous tubo‐ovarian carcinoma

AbstractAimTo compare the immunochemical expression of EGFR, PD‐L1, and the mismatch repair (MMR) proteins MLH1, PMS2, MSH2, and MSH6 between matched malignant effusions obtained before and following the administration of chemotherapy in patients with high‐grade serous tubo‐ovarian carcinoma (HGSC).MethodsIn the enrolled HGSCs, matched formalin‐fixed and paraffin‐embedded cell blocks (CBs) from effusions sampled before (treatment‐naïve patients) and during recurrence (following chemotherapy administration), in addition to their matched HGSC tissues obtained from the ovaries at initial diagnosis (treatment‐naïve patients), were subjected to EGFR, PD‐L1, and MMR immunochemical analysis.ResultsEGFR was more often overexpressed in effusions obtained after chemotherapy administration compared to both effusions (100% vs. 57.1%) and their matched tubo‐ovarian tumors (100% vs. 7.1%) from treatment‐naïve patients, respectively. EGFR immunochemistry was concordant in just 9.1% of the effusions sampled during recurrence and their paired ovarian samples before recurrence. Whereas all HGSC treatment‐naïve samples (ovarian lesions and effusions) were PD‐L1 negative, 3/11 (27.3%) malignant effusions obtained during recurrence showed PD‐L1 overexpression. Lastly, none of the tested HGSC samples exhibited MMR deficiency.ConclusionMeasuring biomarkers using CBs from malignant effusions may provide clinicians with significant information related to HGSC prognosis and therapy selection, especially in patients with resistance to chemotherapy.

Application of immunocytochemical and molecular analysis of six genes in liquid‐based endometrial cytology

AbstractBackgroundThe Yokohama System of Endometrial Cytology has been used for reporting endometrial cytology, which includes gray zone category, atypical endometrial cells (ATEC), subdivided into ATEC‐US and ATEC‐AE. ATEC‐US has been reported to be correlated with malignancy in nearly 10% of the cases. For accurate diagnosis, application of ancillary techniques on endometrial cytology was investigated.MethodsThirty‐seven liquid based cytological specimens (SurePath™) with diagnosis of ATEC or malignant which have corresponding histological specimens, were subjected to immunocytochemical analysis for β‐catenin, ARID1A, and PTEN. Hot spots of mutations for KRAS, BRAF and PIK3CA were evaluated by using i‐densy system (ARKRAY).ResultsIn endometrial samples with the diagnosis of ATEC and malignant, aberrant gene expressions and/or gene mutations for β‐catenin, ARID1A, PTEN, KRAS, BRAF, and PIK3CA were observed in 32.4, 18.9, 37.8, 18.8, 0, and 37.1%, respectively. When any of the genes had aberrant expression or mutation, only sensitivity was better than that of cytology (77 vs. 53.8%). However, specificity, positive predictive value, negative predictive value, and accuracy was better in cytology than those of ancillary techniques. Increasing rate of abnormality according to the consequent histology results was observed in ARID1A (p = .015). Frequent loss of PTEN immunostaining (45.8%) and PIK3CA mutation (43.5%) was observed in the cases with consequent benign histology results.ConclusionIn ATEC category of endometrial cytology, gene expression and mutation analysis of six genes were insufficient to aid conventional cytological diagnoses albeit increased sensitivity. Further investigation would be necessary.

Undifferentiated component of dedifferentiated endometrial carcinoma presenting as a “small round cell” malignancy in a mediastinal lymph node, mimicking small cell carcinoma

AbstractUndifferentiated/dedifferentiated endometrial carcinoma is an uncommon malignant neoplasm of the endometrium that can present as a diagnostic challenge, especially in a metastatic setting. We present a case of a 70‐year‐old woman with a prior endometrial biopsy diagnosed as endometrioid carcinoma, FIGO Grade 2. Chest computerized tomography showed moderate to severe centrilobular emphysema with a 3 mm nodule in the right upper lobe and posterior mediastinal lymphadenopathy. Fine needle aspiration smears of the mediastinal lymph node showed predominantly single and loosely cohesive tumor cells with scant basophilic cytoplasm, prominent nuclear streaking, and molding. Inconspicuous nucleoli and mitotic figures were present. Immunohistochemical (IHC) stains showed the tumor cells were positive for CD56 and synaptophysin but negative for AE1/AE3, CAM5.2, CK7, CK20, TTF‐1, INSM1, chromogranin, CD99, HMB45, SOX10, EBV‐LMP1, and desmin. Flow cytometry was negative for lymphoma. Based on the overall cytologic findings and significant smoking history, a small cell carcinoma could not be excluded. Similar morphologic findings were identified on the corresponding lymph node biopsy. Because of the history of endometrial carcinoma, additional IHC stains (PAX 8, ER, and EMA) were done but were negative. However, the mismatch repair proteins revealed loss of MLH1 and PMS2 with retained MSH2 and MSH6 nuclear expression. Hence, a metastatic undifferentiated component of a dedifferentiated carcinoma from the patients' endometrial primary was favored and subsequently confirmed on the hysterectomy specimen.

Diagnostic value of endometrial cytology and related technology

AbstractBackgroundEndometrial cytology is not much popular in the world, but is commonly used in a few countries. Although cytomorphological evaluation of endometrial cytology is complicating, recent advance in technology helps improve diagnostic accuracy. In addition, new reporting system, The Yokohama System, has been introduced as a standard reporting system resembling The Bethesda System of the uterine cervical cytology. Although sample standardization is one of the causes in diagnostic problem, it was solved by liquid‐based cytology (LBC) technology. In addition, standardized diagnostic algorithm by cytomorphological assessment of LBC samples, the Osaki Study Group (OSG) method, was recently proposed as a reliable and reproducible method. LBC can be utilized for ancillary methods. Application of immunocytochemistry and molecular technology on endometrial cytology samples has been studied to improve diagnostic accuracy. Recent progress of molecular technology has revealed many driver gene mutations in endometrial cancer and its precursors. Surprisingly, many studies revealed that even normal endometrial tissue had driver gene mutations.ConclusionBased on the recent advance in knowledge of molecular profile of endometrial lesions and normal endometrial tissue, endometrial cytology will gain much power in clinical usefulness.

Metastatic mesonephric‐like endometrial adenocarcinoma diagnosed on transbronchial needle aspirate cytology

AbstractMesonephric‐like adenocarcinoma is a relatively rare neoplasm with morphology similar to mesonephric adenocarcinoma but unassociated with mesonephric remnants. Its relatively recent description and rarity make it difficult to diagnose, but it has a high rate of distant metastasis, making distinction from endometrioid carcinoma important. Descriptions of its cytologic features are particularly limited. We describe a case of mesonephric‐like adenocarcinoma diagnosed on transbronchial needle aspiration of the lung, that had been misdiagnosed as endometrioid endometrial adenocarcinoma on a prior hysterectomy. We discuss the characteristic cyto and histomorphology, immunoprofile, molecular alterations, and clinical significance of this uncommon tumor.

Cytodiagnosis of metastatic cervical low‐grade endometrial stromal sarcoma presenting as bilateral adnexal masses

Direct next‐generation sequencing analysis using endometrial liquid‐based cytology specimens for rapid cancer genomic profiling

AbstractBackgroundGenomic examination of cytology specimens is often performed on cell blocks or conventional smears rather than on liquid‐based cytology (LBC) specimens. Since LBC specimens preserve high‐quality DNA, cancer genome profiling using next‐generation sequencing (NGS) is also attainable from residual LBC specimens. One of the advantages of using LBC specimens for NGS is that it allows direct extraction of DNA from residual specimens, avoiding a sacrifice of smear slides and minimizing genomic profiling processing time.MethodsEndometrial LBC specimens were subjected to NGS analysis to validate the practicality of rapid cancer genomic profiling in a pathology laboratory. The extracted DNA was subjected to NGS using a customized cancer gene panel comprising 56 genes and 17 microsatellite regions. The workflow strategy was defined, and the processing time estimated for specimen sampling, cell counting, NGS run, and genome profiling.ResultsNGS analysis of most LBC specimens revealed somatic mutations, tumor mutation burden, and microsatellite instability, which were almost identical to those obtained from formalin‐fixed paraffin‐embedded tissues. The processing time for direct NGS analysis and cancer genomic profiling of the residual LBC specimens was approximately 5 days.ConclusionThe residual LBC specimens collected using endometrial cytology were verified to carry a high tumor fraction for NGS analysis and could serve as an alternate source for rapid molecular classification and diagnosis of endometrial cancers, as a routine process in a pathology laboratory.

Rhabdomyoblasts masquerading as histiocytes: A diagnostic pitfall

How useful are cervical Pap smears in detecting endometrial carcinomas? A tertiary cancer center experience

AbstractObjectiveTo determine the role of routine cervical Pap smears in detecting endometrial carcinomas.MethodA retrospective study was carried out from the histopathology archives for cases diagnosed as endometrial carcinomas with Pap smears within 6 months before histological diagnosis. The demographic details, reports of Pap smears and other tumor parameters on histopathology were noted.ResultsWe identified 380 of 482 cases of endometrial carcinoma with a documented Pap smear within 6 months before histopathogical diagnosis. Out of 380 cases, 187 cases (49.2%) had shown abnormalities on Pap smear of which 80 cases (42%) were diagnosed as atypical glandular cells and 78 cases (41.7%) were diagnosed as adenocarcinoma. The presence of glandular abnormality on Pap smear significantly correlated with the tumor type, myometrial invasion and cervical involvement on histopathology (P < .05). Cases which had higher FIGO staging also had a higher detection rate on Pap smear (P < .05).ConclusionThe Pap smear may help in detection of endometrial carcinoma especially in cases with type 2 endometrial carinomas, tumor with cervical involvement and/or advanced FIGO stage.

Metastatic low‐grade endometrial stromal sarcoma after 24 years: A case report and review of recent molecular genetics

AbstractLow‐grade endometrial stromal sarcoma (LGESS) is a rare malignant uterine tumor with the potential to metastasize years after the primary resection. There is a broad differential diagnosis for endometrial stromal sarcomas (ESS), including both benign and malignant entities. Herein, we present the case of a 64‐year‐old female with metastatic LGESS to the lung, diagnosed by cytology, 24 years after her initial presentation. This report discusses the cytomorphologic and histopathologic characteristics, and ancillary studies including immunohistochemical stains and recent advances in molecular diagnostics of ESS. Accurate diagnosis of spindle cell lesions in the lung can be challenging. As such, this case highlights the instrumental role of ancillary testing and molecular diagnostics to achieve a more definitive diagnosis.

Subcategorization of atypical glandular cells is useful to identify lesion site

AbstractBackgroundIn the subcategorization of atypical glandular cells (AGCs), origin of cells should be mentioned to estimate lesion sites for diagnosis. However, cases without subcategorization are often encountered due to limited reproducibility. We evaluated whether the subcategorization of AGC based on the Bethesda terminology can estimate lesion sites.MethodsWe retrospectively investigated cases whose cervical smears were interpreted as AGC and underwent pathological assessment at our institution between June 2009 and September 2017. AGC was subcategorized based on the Bethesda System. Not‐otherwise‐specified (NOS) was subcategorized into endocervical cells (NOS‐EC), endometrial cells (NOS‐EM), or glandular cells (NOS‐G). Favor neoplastic (FN) was subcategorized into endocervical cells (FN‐EC) or glandular cells (FN‐G). FN‐G was further subcategorized into endometrial cells (FN‐EM) or unknown origin (FN‐UO). Clinicopathological data were retrieved from the medical records.ResultsOf 88 AGC cases, there were 30 NOS‐EC (34.1%), 2 NOS‐EM (2.3%), 25 FN‐EC (28.4%), 22 FN‐EM (25.0%), and 9 FN‐UO (10.2%). A significantly higher proportion of neoplastic lesions occurred in FN than in NOS (P <.001). The concordance of AGC subclass and lesion site was 88.0%, 70.7%, and 77.3% in FN‐EC, FN‐G, and FN‐EM, respectively. The concordance of FN‐EM and lesion site increased to 88.9% in patients aged >50 years. Of nine cases of FN‐UO, six experienced nonendometrioid endometrial cancer and extrauterine malignancy.ConclusionSubcategorization of NOS and FN would be useful in estimating neoplastic lesions. Further subcategorization into FN‐EC, FN‐EM, and FN‐UO would similarly be beneficial in estimating the lesion site, especially for small endometrial and extrauterine lesions.

Does cervicovaginal cytology have a role in the diagnosis and surveillance of endometrial adenocarcinoma?

AbstractObjectiveTo examine the role of cervicovaginal cytology in diagnoses and surveillance of the patients with endometrial carcinoma (EC).MethodsPatients who underwent EC surgery that included a follow‐up were reviewed retrospectively. The cohort was limited to the patients who had an available cervical cytology result within 12 months before the primary surgery took place. The glandular abnormalities were classified in the following subclassifications: “atypical glandular cells” (AGC)‐not otherwise specified (NOS), AGC‐favor neoplasia, endocervical AIS, and adenocarcinoma.ResultsA total of 411 patients were eligible for the study. The cervical cytology was found to be normal and recorded as negative for intraepithelial lesion or malignancy in 368 (89.5%) patients. In 43 (10.5%) patients, cervical cytology was interpreted as: AGC‐NOS (n = 11), AGC‐FN (n = 7), adenocarcinoma (n = 20), malignant epithelial tumor (n = 3), and squamous carcinoma (n = 2). During the follow‐up, recurrence was observed in 53 (12.9%) patients. Among six isolated vaginal cuff recurrences, two of the cases presented with malignant cytology, and the additional four cases were suspected during clinical examination. Among women with recurrence (n = 53), there were malignant cytological findings in four of the patients. In the whole population (n = 411), there were four other abnormal cytological findings detected within the surveillance. These four cytology results were nonmalignant and no recurrence was identified.ConclusionThere is no significant clinical advantage of cervicovaginal cytology testing before diagnosis or during the surveillance of EC.

A case of metastatic HPV‐related cervical small cell neuroendocrine carcinoma with varying cytomorphology found in cytological specimens of a solid organ transplant recipient

AbstractSmall cell neuroendocrine carcinoma (NEC) of the cervix is a rare gynecological malignancy, constituting 2%–5% of all such cases. As high‐risk Human Papilloma Virus (HR‐HPV) infections contribute to 85% of these tumors, small cell NEC poses a significant risk for solid organ transplant recipients, increasing their risk of progressive disease. We present a case of an uterine cervix small cell NEC with metastasis to the bladder and pleural cavities in a 53‐year‐old woman with a past medical history of kidney transplantation, who presented with abnormal uterine bleeding. The initial liquid preparation (ThinPrep) cytology stained with Papanicolaou (Pap) showed an adenocarcinoma not otherwise specified. At the time of diagnosis, the patient had diffusely metastatic disease. A subsequent uterine cervix biopsy was consistent with a small cell NEC. Despite treatment with chemotherapy, the patient's condition deteriorated, evidenced by a worsening right‐sided pleural effusion one‐month postdiagnosis. A pleural effusion showed a tumor with glandular features, with immunohistochemistry suggestive of metastatic adenocarcinoma. HR HPV E6/E7 RNA in situ hybridization (ISH) was positive. Bladder washing showed cytopathologic findings consistent with bladder involvement by small cell carcinoma. The patient's lesions in both urine and pleural fluids showed distinct cytomorphology. Within a year of diagnosis, the patient was declared deceased. This case highlights the existence of carcinoma admixed with NEC tumor, such as an HPV associated adenocarcinoma admixed with a NEC and underscores the elevated risk of HPV‐related genital lesions in renal transplant patients. In patients with a history of solid organ transplant or other immunosuppressive conditions, there is an increased necessity for enhanced surveillance and appropriate cancer screening.

Morphologic Evaluation of Hyperchromatic Crowded Groups Present in Cervical Thin Prep Cytology Tests as Identified by the Hologic Genius Digital Diagnostics System: A Descriptive Study

ABSTRACT Background Our descriptive study focused on morphologic characteristics of hyperchromatic crowded groups (HCGs) in ThinPrep cervical cytology tests when reviewed with the artificial intelligence (AI)‐assisted Hologic Genius Digital Diagnostics System (HGDDS). Method After IRB approval, our archives were searched over a 1‐year period for potential HCGs. A total of 157 slides with HCGs were selected, scanned, and analyzed using the HGDDS. One cytologist and one cytopathologist interpreted these cases while enumerating the cytomorphologic characteristics as seen with the HGDDS. Results Of the 157 cases, a total of 84.7% were called Negative for Intraepithelial Lesion or Malignancy (NILM) on original ThinPrep interpretation (OTPI) as opposed to 76.4% with HGDDS. 5.7% and 3.2% of the cases were called high‐grade squamous intraepithelial lesion (HSIL) and atypical glandular cells (AGC) on OTPI, as compared to 4.5% and 8.3% on HGDDS. 6.4% of cases were interpreted as adenocarcinoma on both OTPI and HGDDS. A total of 16 cases were called NILM‐Atrophy by both modalities. Concordance for pathologist diagnosis between HGDDS and OTPI for 157 cases was 0.610 (kappa value). For 25 cases, there was a follow‐up biopsy diagnosis, including 10 cases of adenocarcinoma, 5 of Cervical Intraepithelial Neoplasia (CIN) 2–3, and 1 case of CIN 1. The sensitivity, specificity, positive predictive value, and negative predictive value for the detection of CIN2+ lesions, when ASC‐H/AGC and above were considered, were 100%, 50%, 75%, and 100%, respectively. Conclusion Our initial study shows encouraging results in the evaluation of HCGs presented as two‐dimensional static images on a computer monitor by the HGDDS.

Clinical Outcomes and Risk Implications of HPV 31 Infection: A 10‐Year Retrospective Cohort Study

ABSTRACT Objective To describe the long‐term clinical outcomes of women diagnosed with human papillomavirus type 31 (HPV 31) infection and to assess its potential implications for genotype‐specific cervical cancer risk stratification in a real‐world screening setting. Methods This retrospective cohort study analyzed 106,450 women screened for cervical cancer at the Afyonkarahisar Cancer Early Diagnosis, Screening, and Education Center (KETEM) between 2015 and 2025. Among 3313 HPV‐positive women, 147 cases with confirmed HPV 31 infection and complete follow‐up data were included. Clinical outcomes, cytology results, and histopathological findings were compared across three groups: isolated HPV 31, HPV 31 co‐infected with HPV 16/18, and HPV 31 co‐infected with other high‐risk genotypes. Results Biopsies were performed in 66 women (44.9%) due to abnormal cytology or HPV 16/18 co‐infection. CIN2+ lesions were detected in 15 patients (22.7% of those biopsied; 10.2% of the entire cohort). The CIN2+ detection rate was 6.0% in isolated HPV 31 infections and 44.4% in women co‐infected with HPV 16/18 ( p  = 0.0006). Notably, 13.9% of cytology‐negative women were diagnosed with CIN2+ on histopathology. Two invasive cancers occurred in women with isolated HPV 31 infection and negative cytology at baseline. Conclusion HPV 31 infection demonstrated measurable oncogenic potential, particularly in cytology‐negative women and those with HPV 16/18 co‐infection. While isolated HPV 31 positivity alone may not warrant immediate colposcopy, these findings support the need for genotype‐specific risk stratification in cervical cancer screening. Further multicenter and prospective studies are required to confirm these results.

Cytology Screening Using Z‐Stack Digital Slides: A Validation Study

ABSTRACTBackgroundFor applications of digital pathology in cytology, challenges such as focal precision and data volume remain. The goals of this validation study are to compare diagnostic accuracy, screening time, annotation counts, and inter‐ and intra‐observer agreement between digital slides using Z‐stack scanning (z‐WSI) and conventional glass slides in liquid‐based cervical cytology (LBC).MethodsWe collected 91 LBC samples, with an equal number of NILM, LSIL, HSIL, and SCC cases. Four cytotechnologists evaluated cases using glass slides and z‐WSI separately. They classified cases under two separate schemas: (1) “Screening‐2‐Category”: NILM (normal) vs. other lesions (ASC‐US and above); and (2) “Morpho‐3‐Category”: NILM vs. LSIL (mild dysplasia) vs. ASC‐H and higher (moderate dysplasia to squamous cell carcinoma) to reflect lesion severity and treatment implications.ResultsFor Screening‐2‐Category classifications, inter‐observer agreement was 0.685 for glass slides and 0.637 for z‐WSI, with intra‐observer agreement ranging from 82.4% to 95.6%. For Morpho‐3‐Category classifications, inter‐observer agreement was 0.700 for glass slides and 0.598 for z‐WSI, indicating reduced agreement with z‐WSI. Accuracy was 91.2% (glass slides) and 87.1% (z‐WSI) for Screening‐2‐Category, and 86.5% and 81.0% for Morpho‐3‐Category, with no significant differences. In both modalities, cytotechnologists tended to apply more annotations in true positive cases but fewer in false negative cases. Screening time for z‐WSI was 2–5 min longer on average for all cytotechnologists.Conclusionz‐WSI is not completely equivalent to glass slides, but it has the potential to be used as a tool for cytology screening. Training specifically designed for WSI is expected to enhance diagnostic accuracy and improve workflow efficiency.

Unsatisfactory Pap Test Results: A Critical Patient Management Problem Pre‐Analytically Addressed by the Cytopathology Laboratory

ABSTRACTBackgroundThe unsatisfactory rate of Pap tests (PT) is an important quality assurance (QA) metric for a cytopathology laboratory. At our institution, an unsatisfactory PT slide is followed by a second ThinPrep (TP) slide. The aim of this study is to evaluate this QA practice.MethodsOur laboratory processes an unsatisfactory TP PT with a follow‐up second TP slide with or without glacial acetic acid. The correlation between the unsatisfactory rate and the second slide rate test was examined.ResultsA total of 2739 cases with a second TP slide were prepared for an unsatisfactory initial TP PT. After second slide preparation, 780 cases (28%) remained unsatisfactory. Using Spearman's rank correlation test, there was a notable negative correlation between the unsatisfactory rate and the second slide rate (rho = −0.42). Of those PTs recategorized as satisfactory TP, 1742 were negative for intraepithelial lesion or malignancy (NILM) (89%), 135 as atypical squamous cells of undetermined significance (ASC‐US) (7%), 37 as low‐grade squamous intraepithelial lesion (LSIL) (1.9%), 11 as atypical squamous cells cannot exclude high‐grade squamous intraepithelial lesion (ASC‐H) (0.6%), 8 as high‐grade squamous intraepithelial lesion (HSIL) (0.4%), and 20 as atypical glandular cells (AGC) (1%). The final Bethesda categorization for all cases and the human papilloma virus (HPV) data was tabulated.ConclusionsA second slide preparation significantly reduced the unsatisfactory rate of the PT. This also had a significant impact by detecting clinically significant lesions. HPV testing can also be performed on slides reclassified from unsatisfactory to ASC‐US or higher.

Determination of Prevalence and Genotype Distribution of High‐Risk Human Papillomavirus in Varamin (Iran)

ABSTRACTCervical cancer is the fourth most common type of female malignancy worldwide. Although appropriate algorithms are available for precise HPV testing in order to manage women with abnormal Papanicolaou smears, region‐to‐region adoption is really critical. The present study aimed at cervical cell cytology assessment as well as HPV genotyping in cervical specimens. A total of 1047 samples of the women who attended for the routine referral indications were examined in four laboratories in Varamin City (Tehran Province) from April 2021 to May 2022. Genetic analysis of cervical cells was performed by PCR and reverse dot blotting. A total of 994 samples were also investigated with Pap staining, and analysis was performed based on the Bethesda 2014 system. Among the total participants with a mean age of 34.2 years, HPV prevalence was detected in 40.12%. The highest HPV infection was determined inthe 31–40‐year‐old population. Furthermore, 22.15% of the detected HPVs belonged to high‐risk genotypes. The most frequent high‐risk HPV genotype was HPV‐16, accounting for 6.78%. In addition, 951 (95.67%) women had normal NILM cytology test results, whereas 43 (4.32%) demonstrated ASC‐US lesions. HPV‐16 was the most prevalent type in ASC‐US lesions. Furthermore, there was a significant association between the high‐risk HPVs and changes in the Pap smear results (p < 0.001). Considering the high prevalence of high‐risk HPV genotypes in the studied population, the genotyping technique is recommended as a priority to determine potential HPV infection, rather than liquid Pap smear analysis as a complementary approach to liquid Pap smear analysis to enhance cervical cancer screening strategies. The findings of this study can contribute to policymaking by providing updated local data on HPV prevalence, which may support vaccination strategies and screening programs in Iran.

Human Papillomavirus Prevalence and Genotype Distribution Among Women With Cervical Cytological Abnormalities in Urumqi, Xinjiang, China

ABSTRACTObjectiveTo investigate the genotype distribution and viral loads of human papillomavirus (HPV) among women with cervical cytological abnormalities in Urumqi, Xinjiang, China.MethodsThe HPV genotyping and viral loads were detected in 9351 patients who underwent the ThinPrep cytology test (TCT) using quantitative real‐time polymerase chain reaction.ResultThe overall HPV infection rate was 21.63%, with a predominance of single and high‐risk HPV (hrHPV) infection. The ethnic stratification showed that the infection rates were 17.01% (265/1558) in Uyghur, 21.76% (84/386) in Kazakh, 22.20% (103/464) in Hui, and 22.79% (1490/6539) in Han. The major hrHPV genotype was HPV53 in Kazakh and HPV16 in Uyghur, Han, and Hui ethnic groups. The age‐stratified data suggested that the highest HPV infection rate in Han, Hui, and Kazakh women was among 25–34 year‐olds, but in the 35–44 year‐old group for Uyghur. The infection rates of HPV16 in cervicitis, ASCUS, LSIL, and HSIL groups were significantly different among the five ethnic groups; the viral load of HPV16 showed a positive correlation with the severity of cervical lesions.ConclusionVariations exist in HPV infection and age distribution among different ethnic groups in Xinjiang, while the HPV16 viral load can guide risk stratification of cervical lesion progression.

Utility of CINtec PLUS in Identification of High‐Grade Lesions on Short‐Term Follow‐Up in Patients With Negative Cytologic Interpretation

ABSTRACTBackgroundScreening for cervical cancer may include cervical cytology and/or high‐risk human papillomavirus testing (HPV). The FDA (Food and Drug Administration)‐approved CINtec PLUS dual stain (DS) for p16 and Ki‐67 can provide helpful information for challenging follow‐up care.MethodsWe retrospectively analyzed 272 cases with negative intraepithelial malignancy (NILM) Papanicolaou (Pap) tests and positive HPV test results. All 272 women had colposcopy‐directed biopsies or endocervical curettage (ECC) (histopathology) within a year. We compared DS test results with corresponding ECC/colposcopy specimens. Two subgroup analyses were conducted to examine the correlation of DS results with a prior history of abnormal Pap/colposcopy and to compare DS results with regard to HPV genotype. For analysis purposes, only high‐grade lesions were considered positive, while low‐grade lesions were grouped with negative results.ResultsOf 272 cases, 113 tested positive for DS, while 159 were negative. On follow‐up histopathology within a year, three of the 113 positive cases (2.6%) showed high‐grade lesions. In comparison, none of the 159 negative cases showed any high‐grade lesions (95% confidence interval [CI]: −0.3% to 5.4% [p = 0.14]). Further analysis by HPV status showed that DS helped in risk discrimination in both subcategories (HPV16/18 and other 12 high‐risk HPV), although it was not statistically significant (p = 0.99). Subgroup analysis based on the history of high‐grade lesions demonstrated that in cases with no previous history, the risk difference was 2.8% between DS positive and negative results (95% CI −0.3% to 6%, p = 0.134).ConclusionAll three high‐grade lesions were in the DS positive category, suggesting DS may help in the risk stratification for HPV‐positive NILM women (either HPV16/18 or other). Furthermore, DS may help with risk stratification, specifically in patients with no prior high‐grade lesions.

Cytology Triage for HPV‐Positive Postmenopausal Women in a Setting of Cervical Cancer Screening

ABSTRACTBackgroundGlobally, cervical cytology continues to serve as the cornerstone of cervical cancer screening programs, but WHO 2021 guidelines advocate HPV DNA testing as the primary screening modality due to its heightened sensitivity. This method necessitates additional triage with cytology or colposcopy to detect precancerous lesions. Hormonal shifts and anatomical alterations in postmenopausal women may impact diagnostic outcomes in either modality.AimTo describe the spectrum of cytological lesions in HPV‐positive postmenopausal women to detect precancerous lesions as part of cervical cancer screening.MethodsConventional cytology smears of high‐risk HPV‐positive postmenopausal women were reported according to The Bethesda System 2014. Results of follow‐up biopsies of the positive smears were recorded, and cyto‐histological correlation was performed.ResultsThe retrospective study included conventional cytology smears of 124 postmenopausal women positive for high‐risk HPV DNA with a mean age of 52 years. Of the 124 cases, 68 were positive for HPV 16 and/or 18, and 56 were positive for other high‐risk HPV. On cytology, 78% were negative for intraepithelial lesions. HSIL+ lesions were noted in 12%, and low‐grade lesions were noted in 10% of smears with HPV16/18 predominance. Follow‐up biopsies of 17 smears revealed SCC in two cases, HSIL+ in 11 cases, LSIL in 2, and 2 were negative/benign lesions. Of the cyto‐histological discordant cases, four were upgraded on review.ConclusionCytology is a useful triage tool in detecting preinvasive and early invasive tumors in HPV DNA‐positive postmenopausal women.

Contaminant Suggesting Rotifer in Liquid‐Based Cytology of the Cervix

ABSTRACTRotifers are rare in cytology, particularly in liquid media. We describe a case of rotifer in liquid‐based cytology of a 30‐year‐old nulliparous woman without comorbidities who complained of vaginal discharge and sought a cervical cancer prevention service with no noteworthy findings on gynecological examination.

Metastatic juvenile granulosa cell tumor in abdominal wall

AbstractJuvenile granulosa cell tumor (JGCT) is an uncommon ovarian tumor. There are only a few cases in the literature that depict the cytomorphology of JGCT at the primary/metastatic site. We described the fine‐needle aspiration cytology of a recurrent metastatic JGCT of the anterior abdominal wall, 5 years post‐surgery (total abdominal hysterectomy with bilateral salpingo‐oophorectomy).

Prevalence of non 16/18 high risk human papilloma virus as a quality metric in gynecological cytology

AbstractHuman papillomavirus (HPV) is the most common sexually transmitted pathogen that causes anogenital disease. Cervical screening by cytology and HPV testing (co‐testing) are important in prevention of cervical cancer. The Bethesda System category of atypical squamous cells (ASC) is used when a neoplastic process cannot be confidently identified. In such cases, the differential diagnosis is broad and includes benign conditions. Monitoring of ASC/SIL ratio is a commonly used laboratory quality assurance measure to prevent over‐ or under‐use of this category. High risk human papillomavirus (hr‐HPV) has been used in conjunction with the ASC/SIL ratio in determining whether a particular pathologist is over/under‐using the indefinite category. However, the laboratory overall sample population prevalence rate of hr‐HPV subtypes has not been previously examined for association with the ASC rate. In this study, the relationships between ASC/SIL ratio and hr‐HPV prevalence rate and hr‐HPV subtypes (16/18 and non‐16/18) to the laboratory ASC prevalence were studied. The results demonstrate that HPV non‐16/18 is the main subtype which is associated with ASC‐US category. A large proportion of non‐16/18 HPV‐related cases are seen in young patients, which largely abates by the by fourth decade. In addition, there are differences in the ASC/SIL ratio for HPV 16/18 and non‐16/18 types. The overall ASC/SIL ratio is an average of the ASC/SIL rate for the non‐16/18 population and the HPV 16/18 population. Instead of basing the laboratory and practitioners' quality indicator solely on ASC/SIL ratio, the overall prevalence of HPV and its subtype ratio should also be reported as they are more reflective of laboratory performance.

Letter to “Correlation of immediate prevalence of cervical squamous cell precancers and cancers with HPV genotype and age in women with LSIL cytology”

Role of scrape cytology smear preparation in the diagnosis of ovarian masses‐utility and pitfalls

AbstractBackgroundScrape cytology technique is useful for rapid intraoperative diagnosis of ovarian mass lesions that acts as an adjunct to frozen section examination. Though ovaries can be accessed by laparoscopy and USG guided FNAC, there are controversial reports regarding the safety of these procedures. The present study has been designed to evaluate the role of scrape cytology in a variety of ovarian mass lesions.ObjectivesTo study the cyto‐morphology of ovarian mass lesions and to evaluate the role of scrape cytology technique in correctly diagnosing the ovarian lesions taking histopathological diagnosis as gold standard.Material and MethodsThis is a prospective observational study done on 61 ovarian mass lesions as received from the Obstetrics and Gynecology department of our Institution.ResultOut of 61 cases, 58 (95.08%) cases were correctly diagnosed with respect to categorization and typing. The age ranged from 14 to 65 years with the mean age being 38.1 years. On histopathology, out of 61 cases, 39 (63.93%) were epithelial along with sub categorization of benign, borderline, and malignant, 13 (22.9%) were germ cell tumors, 5(8.19%) were sex cord stromal tumors, 3 (4.91%) were hemorrhagic cysts and the remaining 1 (1.63%) was massive ovarian edema. Thus, on comparing with histopathology, the sensitivity and specificity of scrape cytology technique were 93.55% and 96.67%, and the diagnostic accuracy was 95.08%.ConclusionScrape cytology of ovarian lesions can give quick and reliable results. Also, proper training of cytopathologists chiefly regarding the sampling technique, gross presentation of ovarian lesions and interpretation of scrape cytology smears is needed. Further studies to provide standard guidelines and reporting criteria will prove to be helpful.

Letter to “Correlation of immediate prevalence of cervical squamous cell precancers and cancers with HPV genotype and age in women with LSIL cytology”

Improving cervical cancer classification in PAP smear images with enhanced segmentation and deep progressive learning‐based techniques

AbstractObjectiveCervical cancer, a prevalent and deadly disease among women, comes second only to breast cancer, with over 700 daily deaths. The Pap smear test is a widely utilized screening method for detecting cervical cancer in its early stages. However, this manual screening process is prone to a high rate of false‐positive outcomes because of human errors. Researchers are using machine learning and deep learning in computer‐aided diagnostic tools to address this issue. These tools automatically analyze and sort cervical cytology and colposcopy images, improving the precision of identifying various stages of cervical cancer.MethodologyThis article uses state‐of‐the‐art deep learning methods, such as ResNet‐50 for categorizing cervical cancer cells to assist medical professionals. The method includes three key steps: preprocessing, segmentation using k‐means clustering, and classifying cancer cells. The model is assessed based on performance metrics viz; precision, accuracy, kappa score, precision, sensitivity, and specificity. In the end, the high success rate shows that the ResNet50 model is a valuable tool for timely detection of cervical cancer.OutputsIn conclusion, the infected cervical region is pinpointed using spatial K‐means clustering and preprocessing operations. This sequence of actions is followed by a progressive learning technique. The Progressive Learning technique then proceeded through several stages: Stage 1 with 64 × 64 images, Stage 2 with 224 × 224 images, Stage 3 with 512 × 512 images, and the final Stage 4 with 1024 × 1024 images. The outcomes show that the suggested model is effective for analyzing Pap smear tests, achieving 97.4% accuracy and approx. 98% kappa score.

Cerebrospinal fluid‐dissemination of a ovarian clear cell carcinoma: A leptomeningial carcinomatosis with diagnostic challenges

AbstractMetastases from ovarian cancer to the central nervous system (CNS) are rare, in particular, isolated leptomeningeal metastases (LM) are extremely rare. The gold standard in the diagnosis of leptomeningeal carcinomatosis (LC) is the detection of malignant cells in cerebrospinal fluid (CSF) cytology. A 58‐year‐old woman diagnosed with ovarian cancer 2 years ago underwent lumbar puncture and CSF cytology in recent months due to new weakness, loss of strength in the lower extremities, and speech disorders. Magnetic resonance imaging CNS was simultaneously visualized and linear leptomeningeal enhancement was demonstrated. CSF cytology showed tumor cells as isolated cells or small clusters of tumor cells with large, partially vacuolated, and abundant cytoplasm, mostly with centrally located nuclei. Given her history of high‐grade clear cell ovarian cancer,CSF cytology was positive for malignant cells and a diagnosis of leptomeningeal carcinomatosis was made by the neuro‐oncology multidisciplinary tumor board. Since LM also implies a systemic disease, the prognosis is very poor, CSF cytology will play an important role in rapid diagnosis and will be useful both in the right choice of treatment and in the early initiation of palliative care.

Correlation of immediate prevalence of cervical squamous cell precancers and cancers with HPV genotype and age in women with LSIL cytology: A retrospective analysis of 1617 cases

AbstractAimsTo evaluate the immediate risk of cervical squamous cell precancers and cancers in women with low‐grade squamous intraepithelial lesion (LSIL) cytology according to different high‐risk human papillomavirus (hrHPV) results and age stratification.MethodsThe study included 1617 women with LSIL cytology and underwent simultaneous Aptima HPV genotyping (E6/E7 mRNA test) followed by cervical biopsy.ResultsAmong 1317 hrHPV positive cases, other 11 types of hrHPV were the most frequent (68.8%), followed by HPV16 (11.1%), HPV18/45 (4.1%), and HPV16/HPV18/45 (0.5%). Compared to other groups, HPV18/45 positive group and other 11 types of hrHPV group showed significantly higher prevalence of intraepithelial neoplasia grade (CIN)1 (p < .0001), while HPV16 positive and HPV16/HPV18/45 dual positive groups showed significantly higher prevalence of CIN2/3 (p < .0001). In addition, hrHPV positive, 25–39 years‐old age group showed a significantly higher prevalence of CIN1 (p = .032) than the other age groups. Furthermore, CIN1 prevalence was significantly higher in patients under 40 or 50 years of age than in those over 40 or 50 years of age (p = .005 and p = .011, respectively). However, there was no significant difference among the different age groups in CIN2/3 prevalence in women with LSIL cytology.ConclusionIn southern Chinese women population, LSIL cytology carries very low immediate risk of high‐grade squamous intraepithelial lesions (HSIL) (CIN2/3) in general. However, HPV16 positive and HPV16/HPV18/45 dual positive indicated a higher immediate risk of high‐grade squamous intraepithelial lesions (HSIL) (CIN2/3). Age is not an immediate risk factor in this patient population for high‐grade squamous lesions or SCC. These results are similar to data from cytology laboratories in the United States and other international settings, therefore strongly support the usage of ASCCP guidelines in this patient population.

Cytologic Histotyping of Gynecologic Malignancies in Peritoneal Fluids Is Reliable When Compared to Its Corresponding Surgical Specimen

ABSTRACTBackgroundCytologic examination of peritoneal fluid (PTFL) often represents the first and only pathologic specimen available to guide management of gynecologic malignancies (GMs). This study examines the cytohistologic correlation between histotyping of GM in PTFL and its corresponding surgical specimen (SS).MethodsThe study retrospectively identified positive PTFL with a GM between 2017 and 2022. Cytologic specimens (CSs) that were obtained after or concurrently with its diagnostic SS (biopsy/resection) were excluded. Root cause analysis of discordant cases was performed by reviewing morphology, specimen characteristics, and immunophenotype of CS.ResultsGM affected 55.8% (502/899) of malignant PTFL, of which 15.7% (79)/22.3% (112) was the only/initial diagnostic sample, respectively. Compared to SS, when a subtype was rendered on CS (91.9%), the concordance rate is 91.2% (almost perfect agreement, K = 0.842). Factors contributing to incorrect/inadequate subtyping include specimen limitations (low volume and/or cellularity), cytopathologist preference, and insufficient immunophenotyping. In seven patients (1.4%), the CS was able to render a more definitive diagnosis than its preceding nondiagnostic SS due to the paucity of lesional cells.ConclusionWhen compared to SS, histotyping of GM in PTFL is reliable and, at times, can be more definitive than its surgical counterpart. In some cases, subtyping is limited by extrinsic factors (i.e., specimen limitations). In other cases, the responsible cytopathologist prefers not to subtype despite supportive morphologic and immunohistochemical features. This highlights an opportunity for improvement in the diagnosis/subtyping of GM in PTFL, which may be the initial or only diagnostic specimen prior to patient treatment.

In‐Depth Assessment of Cytologic Features in 106 Cervical Papanicolaou Tests of Transgender Male Patients on Testosterone: An Institutional Experience

ABSTRACT Background There is a decreased cervical cancer screening rate among female to male transgender (FTMTG) patients. Data on the distinct cytologic features present in cervical cytology (CC) of those on testosterone therapy is limited. Methods An 2017–2023 electronic database search identified CC specimens from a cohort of FTMTG patients on testosterone therapy (TT). A morphologic retrospective review of CC for cellularity and presence of key morphologic features was performed. Records were reviewed for original cytologic diagnoses and concurrent HPV test results for comparison with a cisgender female (CF) cohort. Results 106 of 132,363 (0.08%) identified CC specimens were from FTMTG patients on TT. Diagnostic rates were compared to the CF population. The most common diagnosis for both groups was “negative for intraepithelial lesion or malignancy”. The unsatisfactory rate was significantly higher in the FTMTG cohort at 21.7% (vs. 2.7%). The comparative HPV positivity rate of FTMTG and CF cohorts was 13.2% and 10.7%, respectively. Of 83 FTMTG satisfactory CC specimens, 67% showed low cellularity (narrowly meeting the adequacy threshold of 5000 well‐visualized squamous cells) and 78% showed extensive squamous atrophy. Nuclear grooves and irregular contours (features associated with transitional cell metaplasia) were observed in 18% and 23%, respectively. High N:C ratio was noted in 20% of cases. Conclusion The higher unsatisfactory rate in FTMTG patients raises the question of whether adequacy criteria for this cohort should be adjusted. To enhance diagnostic accuracy, providing an accurate clinical history may prevent overinterpretation of features associated with transitional cell metaplasia.

An unusual case of carcinoma with mesonephric‐like features with a spindle cell component diagnosed on the Pap test of the uterine cervix: Cytomorphologic and immunophenotypic features and diagnostic pitfalls

AbstractMesonephric‐like adenocarcinomas (MLA) are rare neoplasms arising in the cervix, endometrium, and ovary. In contrast to mesonephric carcinomas (MC), mesonephric‐like adenocarcinomas are not associated with mesonephric remnants. Both entities have a similar appearance with regards to varying histomorphology patterns, including glandular, tubular, spindled, solid, and papillary, and have a specific immunophenotype and molecular features. We present a case of a 54‐year‐old HPV‐negative woman with a Pap test that exhibits high‐grade malignancy. The cell block displayed malignant cells with positive stains for PAX8, GATA3, and TTF1 by immunohistochemistry. The diagnosis of adenocarcinoma with mesonephric like features was rendered. MLA can be challenging on the small specimens and often misinterpreted as other endometrial neoplasms. Furthermore, the accurate diagnosis carries a well‐described risk of aggressive clinical behavior.

Commentary on “Comparison of glass and digital slides for cervical cytopathology screening and interpretation”

Comparison of glass and digital slides for cervical cytopathology screening and interpretation

AbstractCervical cancer is the second most common form of cancer and a leading cause of premature death among women aged 15 to 44 worldwide. In Brazil, there is a high prevalence of infection by the human papillomavirus – HPV. Digital pathology optimizes time and space for reading cervicovaginal cytology slides. We evaluated the feasibility of using whole slide images (WSI) for the routine interpretation of cytology exams. A total of 99 cases of vaginal cytology were selected from a reference laboratory in Northeastern Brazil. Three cytotechnicians participated in the study. Cellular atypia was the one that most presented concordance values. Two observers almost perfectly agreed (k = 0.86 and k = 0.84, respectively) on the negative diagnoses. The performance of the evaluators for NILM (negative for intraepithelial lesion and malignancy) showed high reproducibility and sensitivity in the digital slides, mainly between evaluators A and C. In contrast, the microbiology group showed disagreement between the diagnoses by digital slides and the standard‐ gold. The concordance between the digital diagnoses and the gold standard for ASCUS was 89%. In the inflammatory category, Spearman's test showed similar results between raters A, B, and C (rs = 0.47, rs = 0.41, and rs = 0.47, respectively). This study reports the diagnostic validation using digital slides in view of the need to optimize the cytology visualization process. Our experience shows good diagnostic agreement between digital and optical microscopy in several analyzed categories, but mainly in relation to cellular atypia and inflammatory processes.

Immediate histopathologic correlation in Turkish population with negative cytology and high‐risk human papillomavirus positivity: A retrospective analysis of high‐risk human papillomavirus genotype and stratified by age

AbstractIntroductionAccording to the American Society of Colposcopy and Cervical Pathology (ASCCP) recommendations, regardless of age, women with high‐risk infections other than human papillomavirus 16/18 positivity (other hrHPV) and negative cytology should not be referred directly to colposcopy. Several studies compared detection rates of ≥high‐grade squamous intraepithelial lesion (HSIL) between HPV 16/18 ± 45, and other hrHPV types on colposcopic biopsy.MethodsWe designed a retrospective study to determine the presence of ≥HSIL in colposcopic biopsy in women with negative cytology and hrHPV positivity during the years 2016–2022.ResultsHPV 16/18/45 had a PPV of 43.8%, while other hrHPV types had a PPV of 29.1% for a tissue diagnosis of ≥HSIL. For a tissue diagnosis of ≥HSIL detection, there was no statistically significant difference between the PPV of other hrHPV and HPV 16/18/45 in patients ≥30. There were only two cases with a tissue diagnosis of ≥HSIL in the other hrHPV group of women under 30 years of age.ConclusionWe suggested that the follow‐up recommendations of ASCCP for patients above the age of 30 with negative cytology and other hrHPV positivity may not be fully applicable to countries like Turkey with a different healthcare environment. Referring to patients ≥30 who had other hrHPV positivity and negative cytology to direct colposcopy may be clinically beneficial, particularly in populations where a colposcopic examination is easy and inexpensive.

Cytohistopathologic correlation of ovarian mesonephric‐like carcinoma and female adnexal tumor of probable Wolffian origin

AbstractRecently we encountered two cases with mesonephric features, mesonephric‐like carcinoma (MLC) of the ovary, and female adnexal tumor of probable Wolffian origin (FATWO). They are thought to be related to mesonephric remnants (or Wolffian duct remnants). Herein we describe the cytohistolgical features, differential diagnoses, and potential pitfalls in diagnosis of these neoplasms. On cytological examination, the case of MLC showed tight 3‐dimensional clusters of overlapping round cells, corresponding to solid growth pattern seen on histological examination. Tubular architecture and papillary formations composed of neoplastic cells of medium size with scant cytoplasm were readily identified. Intraluminal eosinophilic secretions were better seen on histological examination. Additionally, areas resembling features of papillary thyroid carcinoma were noted. Mitoses and apoptotic bodies were not identified on cytology but seen on histological sections. The neoplastic cells were positive for CK7, CD10, PAX‐8, TTF‐1, and GATA‐3, and negative for ER, PR, and WT‐1 immunostains. In contrast to MLC, cytological examination of FATWO showed smaller oval to spindle monotonous cells without mitotic figures. Some cells contained paranuclear vacuoles and were arranged individually or in loose cohesive clusters. Other cells were closely associated with pericellular hyalinized basement membrane‐like material and they were arranged in cohesive clusters as well. On histological examination, similar to MLC, the FATWO had areas with thyroid‐like features, such as, intraluminal eosinophilic secretions, paranuclear vacuoles, in the background of collagenous stroma. The neoplastic cells were positive for CK AE1/AE3, calretinin, WT‐1, inhibin, and CD10, and negative for CK7, PAX‐8, GATA‐3, ER, PR, and C‐kit immunostains.

Cytological features of ovarian or tubal high‐grade serous carcinoma: A retrospective study of 12 cases with abnormal cervical liquid‐based smear

AbstractBackgroundHigh‐grade serous carcinoma (HGSC) is the most common epithelial carcinoma of the tubo‐ovarian region, with a poor prognosis, which presents with an advanced stage at the time of diagnosis. This study summarizes the cytological features of cervical liquid‐based cytological examination in order to diagnose ovarian or tubal HGSC at an early stage by cervical cytology smear.MethodsA total of 12 patients who were diagnosed with atypical glandular cell (AGC) and above lesions by cervical cytological examination and ovarian or tubal HGSC by histopathology were enrolled in this study. The cytological characteristics, including the arrangement and shape of the neoplastic cells, nuclear and cytoplasmic features, and the presence of tumor diathesis were reviewed.ResultsNine cases were determined to be AGC, and three cases were determined to be AGC favor neoplastic (AGC‐FN) in the 12 cervical cytological diagnoses. The glandular cells showed significant atypia and proliferated actively with a three‐dimensional structure. Increased nuclear‐to‐cytoplasmic ratios, prominent nucleoli, and hyperchromasia were common. Vacuole‐like changes were observed in the cytoplasm. Tumor diathesis was observed in only one case (1/12, 8.30%).ConclusionOvarian or tubal HGSC can occasionally be detected using cervical liquid‐based cytology. It has distinct cytological characteristics. Primary ovarian or tubal HGSC with positive cervical cytology was accompanied by tumor cells in ascites, which suggested that the patient had progressed to an advanced stage.

Evaluating the Cytomorphologic Features of Cervical Adenosquamous Carcinoma

ABSTRACTPrior studies suggest that adenosquamous histology confers a poorer prognosis when compared with other histologic subtypes of carcinoma in the cervix. However, there is limited literature describing the cytologic features of this entity. Herein we report on a series of adenosquamous carcinomas of the uterine cervix diagnosed within our institution to evaluate the range of cytomorphologic features and integrate clinical and genotypic data.

Cervical lymph node metastasis of ovarian dysgerminoma: A case report with fine needle aspiration cytology

AbstractDysgerminoma is a rare germ cell tumor, accounting for 1% to 2% of all malignant ovarian tumors. Here, we report a case of dysgerminoma diagnosed by aspiration cytology of a cervical lymph node. A 20‐year‐old woman presented with an abdominal mass and left cervical swelling. CT revealed a large pelvic tumor, along with a nodular lesion on the left side of neck. Fine needle aspiration (FNA) cytology of a cervical lymph node showed large atypical cells and small lymphocytes. Immunocytochemical staining on cell block material revealed that these large tumor cells were positive for placental alkaline phosphatase, D2‐40, and c‐kit. Dysgerminoma was suggested by FNA cytology. Furthermore, bilateral oophorectomy was performed, and histology confirmed the diagnosis of ovarian dysgerminoma. FNA cytology of metastatic lymph nodes along with immunocytochemistry is a useful tool for diagnosis of dysgerminoma.

Highly differentiated follicular carcinoma of ovary: Use of imprint cytology at intraoperative consultation

AbstractHighly differentiated follicular carcinoma of ovary (HDFCO) is a rare entity known to arise in struma ovarii. Clinical presentation and radiological features mimic other cystic ovarian neoplasm. Thus, intraoperative diagnosis of this entity can be challenging. We hereby report a HDFCO case of a 52‐year‐old woman, who presented with significant abdominal bloating for 3 months. Imaging showed a 11.7 cm left adnexal‐mixed cystic and solid mass, adhering to the bowel with ascites. The mass was examined intraoperatively and showed multilocular cysts filled with straw or red brown‐colored gelatinous fluid. Microscopically, the tumor consisted of small and large follicles with proteinous material and bland‐looking cuboidal cells, suspicious for struma ovarii or granulosa cell tumor with extensive cystic changes, while imprint cytology slides showed watery colloid with cracking artifact favoring the former. However, the adherence to the bowel suggested HDFCO, and prompted surgical staging. The histology of the ovarian mass in the permanent section resembled goiterous thyroid tissue with invasion of endocervical stroma, uterine wall and colonic serosa, and presence of tumor nodules in omentum leading to the diagnosis of HDFCO. Due to striking resemblance of HDFCO to benign thyroid goiter, searching for invasive and metastatic foci is crucial for correct diagnosis. In addition, intraoperative imprint cytology revealing colloid with cracking artifact is helpful for differentiating struma ovarii and/or HDFCO from other ovarian lesions.

A Retrospective Analysis of 1151 Chinese Women With Atypical Glandular Cells: Impact of High‐Risk Human Papilloma Virus Status and Age on Cervical and Endometrial Neoplasia Risk

ABSTRACTObjectiveTo investigate the clinical significance of high‐risk human papillomavirus (hrHPV) testing and age in women with atypical glandular cells (AGC) on Pap tests.MethodsWe retrospectively analyzed the relationship between hrHPV and cytology co‐testing, follow‐up histopathology within 6 months, age, and other demographic features in a large cohort of AGC patients from a single Chinese academic institution.ResultsAmong1510 AGC patients, 1151, 1260, and 866 patients had histopathologic results, hrHPV co‐testing, and both, respectively. High‐grade squamous intraepithelial lesions (HSIL)/adenocarcinoma in situ (AIS) and worse lesions (HSIL/AIS+) and endometrial atypical hyperplasia (EAH)/endometrial carcinoma (EC) (EAH/EC+) were present in 27.8% (281/1009) and 25.1% (113/450) patients, respectively. hrHPV was positive in 34.5% (435/1260) patients. Among hrHPV+ patients with genotyping by the Aptima assay, 48.8% (125/256) had HPV16 and/or 18/45. Compared to hrHPV− patients, hrHPV+ women had a significantly increased risk of HSIL/AIS+ (OR: 10.958, 95% CI: 7.657–15.682), particularly with HPV16 and/or18/45 (OR: 3.556, 95% CI: 2.122–5.959; both p < 0.001). Among hrHPV− patients, those aged ≥ 40 years had higher risks of HSIL/AIS+ (including 18 HPV‐independent and 11 metastatic adenocarcinomas; OR: 5.882, 95% CI: 2.702–12.806) and EAH/EC+ (OR: 7.622, 95% CI: 3.188–18.225) compared to younger patients (both p < 0.001).ConclusionsCombining hrHPV testing and age effectively stratifies risks in AGC patients: hrHPV positivity predicts high‐grade cervical lesions, while older hrHPV‐negative women are more likely to have endometrial or extra‐uterine malignancies. These findings may optimize management of AGC patients with cumulative supportive data.

Utility of SOX17 Immunohistochemical Stain in Serous Fluid Cytology Cell Block Specimens

ABSTRACTBackgroundThe identification of metastatic tumors in serous fluid cytology specimens (SFCS) has always been a challenge. In this study, we explored SOX17 as an immunohistochemical (IHC) marker for the diagnosis of metastatic gynecologic tumors in body fluid specimens.MethodsWe selected 97 tumor cases, including 85 SFCS with adequate cell block material (from gynecologic primary, n = 30 and others, n = 55) and 12 histology specimens (thymic and thyroid tumors). SOX17 IHC was performed on all selected cases, and results were interpreted as positive or negative. Positive results were further characterized by intensity (nuclear staining) as weak (1+), moderate (2+), and strong (3+) and percentage of positive cells as focal (< 10%), patchy (10%–50%) and diffuse (> 50%).ResultsIn SFCS of gynecologic primary tumors, SOX17 exhibited strong nuclear staining in 28 out of 30 tumors, with two cases showing moderate staining. All non‐gynecologic metastatic tumors in effusion cytology specimens were SOX17‐negative except for one case of renal cell carcinoma, which displayed a moderate patchy staining pattern. All histology cases consisting of thymic and thyroid tumors were negative for SOX17.ConclusionsIn this study, all tumors of gynecologic tract origin in effusion SFCS were SOX17 positive, while all other non‐gynecologic tumors were negative for SOX17 except for one case. This finding suggests that SOX17 IHC is an excellent addition to the IHC panel while working up tumors at metastatic sites, specifically when gynecologic primary tumors are in the differential diagnosis.

Oxyphilic clear cell carcinoma of the ovary: A distinct cytomorphological finding

Clinician's commentary: Atypical peritoneal cytology in ovarian and endometrial cancers

AbstractPeritoneal cytology results play an important role in staging, prognostication, and treatment recommendations in early‐stage ovarian cancer. In endometrial cancer, while no longer part of staging criteria, peritoneal cytology results can influence patient‐provider shared‐decision making regarding adjuvant therapy choices after definitive surgery. We explore two cases demonstrating the impact uncertain cytology can have on patients and providers in these two gynecologic cancers.

Detecting FR ‐⍺ Expression Level in Cytology Effusion Specimens From Ovarian Cancer and Comparing It With Tissue Specimens

ABSTRACT Background Folate receptor‐⍺ (FR‐⍺) is an attractive target for targeted therapy. Mirvetuximab soravtansine (MIRV) has been approved by the United States Food and Drug Administration (FDA) for treating adult patients with FR‐⍺ positive, platinum‐resistant epithelial ovarian cancer, fallopian tube cancer, or primary peritoneal cancer. Therefore, identifying and detecting FR‐⍺ has become an essential part of precision medicine. This study aimed to evaluate the feasibility of detecting FR‐⍺ protein expression in serous cavity effusions using cell blocks (CBs) and compare the results with surgical pathology biopsy or resection specimens. Furthermore, we investigated potential variations in FR‐⍺ expression pre‐ and post‐chemotherapy. Methods Immunohistochemical (IHC) staining of FR‐⍺ was performed on the serous cavity effusion specimens from 35 patients with epithelial ovarian cancer, along with matched surgical pathological (SP) biopsy or resection specimens, following the manufacturer's guidelines for IHC analysis. Results Positive staining was observed in 30 (85.7%) and 32 (91.4%) serous cavity effusion CB and tissue samples, respectively. A total of 31 (88.5%) tissue and 28 (80%) effusion CB samples exhibited moderate‐to‐strong FR‐⍺ expression in at least 25% of tumor cells. A cutoff of 25% for FR‐⍺ expression positivity was used to demonstrate high concordance (96.4%) between cytology CBs and tissue specimens. We recommend a cutoff of 75% viable tumor cells with moderate‐to‐strong membrane staining as “positive” in CBs for greater reliability, which aligns with FDA‐approved criteria. A reasonable consistency was observed in FR‐⍺ expression between the pre‐treatment serous cavity effusion CB specimens and the new biopsy specimens obtained after multiline treatment. Conclusion We demonstrated that serous effusion CB specimens may be effective for FR‐⍺ biomarker detection; FR‐⍺ maintains stable expression pre‐ and post‐chemotherapy, and patients can benefit from MIRV.