Outcome of cervical cytopathology cases reported as glandular neoplasia

1. V. Willis, A. T. Williams Royal Sussex County Hospital May 2010 Outcome of cervical cytopathology cases reported as glandular neoplasia

2. Background Glandular abnormalities are identified in only a small proportion of the total smears reported each year Between 2008 and 2009 <0.1% of adequate cervical cytology samples contained suspected invasive carcinoma or glandular neoplasia Borderline changes were found in 3.7% of adequate samples (category includes squamous as well as glandular changes)1

3. ?glandular neoplasia Dyskaryotic cells with cytological features suggesting CGIN or invasive endocervical adenocarcinoma, endometrial adenocarcinoma or extra-uterine adenocarcinoma Result code 6

4. Borderline glandular Equivocal changes in endometrial or endocervical cells Result code 8 Regarded as a special category – immediate referral to colposcopy as with code 6

5. Significance Atypical glandular cells may indicate significant underlying pathology including co-existing squamous abnormalities Cytologically detected atypical cells has also been shown to be predictive of significant cervical pathology even when colposcopy is normal2

6. Aim of study To compare cytological and histological reports and determine the positive predictive value of smears reported as glandular neoplasia or borderline glandular changes Compare PPV to other recent studies in the literature Standards – No local or national standards for achieving a certain PPV are available

7. Methods 106 cervical cytology reports were retrospectively identified Group 1 - coded as ?glandular neoplasia Group 2 - coded as borderline glandular Royal Sussex County Hospital cytology department over a 5 year period (Jan 2005 – Dec 2009) Cases included screening samples obtained in primary care and those from colposcopy and gynaecology clinics Repeat smears from same person were excluded

8. Methods Local electronic database used to search for: Age Clinical history on cytology request form Free text on cytology report Subsequent treatment Histology report (biopsy, LLETZ or hysterectomy specimens) Data was analysed and histological diagnosis compared with cervical cytology Neither cytology nor histology was reviewed

9. Results – statistics Group 1 (code 6) Total number of cases: 50 Age range: 29 – 85 (mean 49 years) Group 2 (code 8) Total number of cases: 56 Age range: 22 – 86 (mean 44)

10. Results – group 1

11. Results – group 1

12. Results – group 1 Correlation with cytology: PPV = 44% PPV = 52% excluding no follow up record PPV for epithelial abnormality (squamous or glandular) = 81%

13. Results – group 2

14. Results – group 2

15. Results – group 2 Correlation with cytology: PPV = 13% PPV = 17% excluding no follow up record PPV for epithelial abnormality (squamous or glandular) = 56%

16. Comparison groups 1 and 2

17. Free text on cytology

18. Free text on cytology

19. Difficulties in identification of glandular neoplasia None of architectural features are entirely specific for neoplastic change in endocervical cells Dyskaryosis may be subtle and vary from cell to cell CGIN lesions may include some nuclei which are indistinguishable from normal Benign processes may be over-called e.g. tubo-endometrial hyperplasia, cervical endometriosis and lower uterine segment sampling

20. Discrepancies – group 1

21. Discrepancies – group 2

22. Discussion The PPV for both groups are lower compared to a recent study (‘Outcomes of cervical liquid-based cytology suggesting a glandular abnormality’)3 ?glandular neoplasia – 52% cf. 75.4% Allowing for factors affecting interpretation: 52%  to 58% Borderline change – 17% cf. 24.1% Allowing for factors affecting interpretation: 17%  to 21%

23. Discussion The overall PPV for clinically significant lesions in a ?glandular smear is however comparable to other studies in the literature 81% cf. 80.6%4 The overall PPV for clinically significant lesions in a borderline glandular smear is also comparable to other studies 56% cf. 56%5 Furthermore this result supports the for need for colposcopy in cases reported code 8

24. Limitation of this audit Case notes were not reviewed and additional factors affecting cytological interpretation may have been overlooked Type of smear not taken into consideration Widespread use of liquid-based cytology at RSCH beginning 2008 Over half the cases (58% group 1, 50% group 2) are of conventional type preparation

25. Recommendations for improvement Set local standards Relevant history should be clearly stated on cytology request form as over-interpreting benign changes may result in unnecessary treatment In cases with a discrepancy between cytology and histology, slides should be reviewed for educational purposes Re-audit in 1 year

26. References 1. http://www.cancerscreening.nhs.uk/cervical/statistics.html 2. Ullal, A. et al. The role of cervical cytology and colposcopy in detecting cervical glandular neoplasia. Cytopathology. 2008. 20, 359-366 3. Finall, A. I. et al. Outcomes of cervical liquid-based cytology suggesting a glandular abnormality. Cytopathology. 2009. 20, 367-374 4. Kirwan, J. M. et al. A retrospective clinical audit of cervical smears reported as 'glandular neoplasia'. Cytopathology. 2004. pp. 188-194(7) 5. Mohammed, D. K. et al. A clinical review of borderline glandular cells on cervical cytology. BJOG. 2000. May;107(5):605-9

27. Acknowledgements • Thanks to J. Rankin and A. Baker for data collection