Role of HPV genotyping in risk assessment among cytology diagnosis categories: analysis of 4562 cases with cytology-HPV cotesting and follow-up biopsies.

OBJECTIVE: Human papilloma virus (HPV) detection and genotyping are increasingly used in clinical risk assessment. We aimed to analyze HPV genotyping performance in risk stratification among cytology diagnosis categories. METHODS: Between January 1, 2015 and December 31, 2016, 4562 cases with cytology-HPV co-testing and biopsy follow-up were identified. HPV tests were performed on Cobas (n=3959) or Aptima (n=603) platforms. Of the biopsies, 669 demonstrated high-grade squamous intraepithelial lesions or worse. RESULTS: Pooled high-risk HPV testing had high overall sensitivity (97%) but low specificity (20%) and positive predictive value (20%) for biopsy-confirmed high-grade squamous intraepithelial lesions or worse. HPV16/18 genotyping had considerably improved specificity (81%) and positive predictve value (35%) in predicting high-grade squamous intraepithelial lesions or worse, especially in atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesion categories. Significantly more biopsy-confirmed high-grade squamous intraepithelial lesions or worse were detected by Aptima than Cobas testing, as measured by HPV16/18 (48% vs 33%, p<0.001), non-16/18 high-risk HPV (18% vs 13%, p=0.029), or all high-risk HPV genotypes (27% vs 19%, p<0.001). Aptima genotyping showed a significantly higher positive predictive value than Cobas genotyping for biopsy-confirmed high-grade squamous intraepithelial lesions or worse in the atypical squamous cells of undetermined significance category (47% vs 23%, p<0.05). CONCLUSIONS: HPV genotyping was sensitive for biopsy-confirmed high-grade squamous intraepithelial lesions or worse in all cytologic categories, and is particularly valuable in risk evaluation for women with atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesions. The triaging role was greatly diminished in high-risk lesions (atypical glandular cells, atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesions and high-grade squamous intraepithelial lesions) due to low specificity and positive predictive value. Aptima performance in risk management was superior to Cobas, with significantly higher positive predictive value for biopsy-confirmed high-grade squamous intraepithelial lesions or worse. Our results highlight the importance of careful data interpretation from studies using different HPV testing methods and the need to incorporate HPV E6/E7-mRNA testing into management guidelines.

Aptima Human Papillomavirus E6/E7 mRNA Test Results Strongly Associated With Risk for High-Grade Cervical Lesions in Follow-Up Biopsies.

OBJECTIVE: Human papillomavirus (HPV) tests and genotyping (GT) have been used in clinical risk assessment. The purpose of this study was to analyze the performance of 2 common HPV testing platforms in risk evaluation for high-grade cervical lesions. MATERIALS AND METHODS: Between January 1, 2015, and December 31, 2016, a total of 4,562 Pap tests with follow-up biopsies in our laboratory database were analyzed along with HPV tests performed on Cobas (CHPV, n = 3,959) or Aptima (AHPV, n = 603) platforms. RESULTS: The sensitivity for biopsy-confirmed HSIL or worse lesions was 97% for both CHPV and AHPV (p = .75). AHPV showed significantly lower positive rates than CHPV in benign (56% vs 86%) or LSIL (66% vs 90%) biopsies, resulting in significantly higher specificity for HSIL or worse than CHPV (38% vs 12%, p < .001). AHPV demonstrated significantly higher positive predictive value for HSIL or worse (24% vs 16%, p < .001) and overall accuracy (48% vs 24%, p < .001) than CHPV. AHPV GT also had significantly higher specificity for biopsy-confirmed HSIL or worse than CHPV (88% vs 72%, p < .001) with comparable sensitivity (50% vs 51%, p = .75). Women with HPV 16 on AHPV were significantly more likely to have HSIL or worse on biopsies than those with HPV 16 on CHPV (likelihood ratio = 4.3 vs 2.0, p = .004). CONCLUSIONS: Although both AHPV and CHPV were highly sensitive for biopsy-confirmed HSIL or worse lesions, AHPV and GT demonstrated significantly higher specificity and positive predictive value than CHPV. The difference is probably related to E6/E7 overexpression after viral DNA integration in high-grade lesions. The significantly higher specificity and overall accuracy of AHPV and GT for HSIL or worse lesions may be useful in clinical risk management.

Atypical glandular cells in Pap tests: cytology-histology correlation and risk assessment with human papillopmavirus (HPV) testing.

INTRODUCTION: Atypical glandular cells (AGC) represent less than 1% of Pap test cases and include a variety of lesions in both the cervix and endometrium. The study aimed to investigate the cytology-histology correlation in AGC patients and to evaluate the clinical utility of hrHPV testing in this diagnostic context. MATERIALS AND METHODS: We identified 491 atypical glandular cells (AGC) cases in our quality analysis (QA) database of 336,064 Pap tests interpreted between March 1, 2013 and July 12, 2016. Of these, 251 cases had follow-up biopsies with hrHPV tests in 148 cases. RESULTS: The most common histologic diagnosis associated with AGC was normal/benign or low-grade lesions, comprising 55% of cervical biopsies and 24% of endometrial biopsies. High-grade lesions were identified in 21% of follow-up biopsies. In patients with AGC cytology, a positive hrHPV test significantly increased the likelihood of cervical HSIL or above lesions on biopsy by 26.4 times (OR = 26.4, 95% CI: 5.8-119.4, P < 0.0001). A positive genotyping result for HPV 16 dramatically increased the likelihood of cervical HSIL or above lesions on biopsy (OR = 84, 95% CI: 12.0-590.5, P < 0.0001). The HPV test had a negative predictive value of 97% (CI: 85%-100%). CONCLUSIONS: Our study confirms that AGC is a significant diagnosis with an overall risk for high-grade cervical or endometrial lesions as high as 21%. hrHPV testing with genotyping is an effective tool for identifying high-risk individuals within the AGC population, with excellent positive and negative predictive values. This approach is valuable for clinical risk stratification and differential diagnosis in patients with AGC cytology.

Current State of Cytologic-Histologic Correlation Implementation for North American and International Laboratories: Results of the College of American Pathologists Cytopathology Committee Laboratory Practices in Gynecologic Cytology Survey.

CONTEXT.­: The College of American Pathologists (CAP) updated the Laboratory Accreditation Program Cytopathology Checklist to assist laboratories in meeting and exceeding the Clinical Laboratory Improvement Amendments standards for gynecologic cytologic-histologic correlation (CHC). OBJECTIVE.­: To survey the current CHC practices. DESIGN.­: Data were analyzed from a survey developed by the committee and distributed to participants in the CAP Gynecologic Cytopathology PAP Education Program mailing. RESULTS.­: Worldwide, CHC practice is nearly universally adopted, with an overall rate of 87.0% (568 of 653). CHC material was highly accessible. CHC was commonly performed real time/concurrently at the time the corresponding surgical pathology was reviewed. Investigation of CHC discordances varied with North American laboratories usually having a single pathologist review all discrepant histology and cytology slides to determine the reason for discordance, while international laboratories have a second pathologist review histology slides to determine the reason for discordance. The cause of CHC discordance was primarily sampling issues. The more common statistical metrics for CHC monitoring were the total percentage of cases that correlated with subsequent biopsies, screening error rate by cytotechnologist, and interpretative error rate by cytotechnologist. CONCLUSIONS.­: Many laboratories have adopted and implemented the CHC guidelines with identifiable differences in practices between North American and international laboratories. We identify the commonalities and differences between North American and international institutional practices including where CHC is performed, how CHC cases are identified and their accessibility, when CHC is performed, who investigates discordances, what discordances are identified, and how the findings affect quality improvement.

p16(INK4a) and ProEx C immunostains facilitate differential diagnosis of hyperchromatic crowded groups in liquid-based Papanicolaou tests with menstrual contamination.

OBJECTIVE: Evaluation of hyperchromatic crowded groups in Papanicolaou (Pap) tests from women during menstruation can be a diagnostic pitfall due to similar morphological appearances with significant cervical lesions. We studied the results of p16(INK4a) and ProEx C on cell blocks from Pap tests during menstruation in an attempt to facilitate the differentiation. STUDY DESIGN: Immunohistochemical stains for p16(INK4a) and ProEx C were performed on 25 cell blocks prepared from residual liquid-based cervical material with menstrual contamination. RESULTS: Strong, diffuse, and full thickness staining pattern for p16(INK4a) and ProEx C was observed in cases of high-grade squamous intraepithelial lesion (HSIL) and small cell carcinoma of the cervix. The low-grade squamous intraepithelial lesion cases and cases negative for intraepithelial lesion or malignancy were negative for ProEx C, with focal staining for p16(INK4a). The benign endometrial cells had either negative or focal patchy staining, which is often associated with tubal metaplasia. CONCLUSION: p16(INK4a) and ProEx C are sensitive markers for identifying significant lesions in Pap test specimens with menstrual contamination. Patchy/mosaic staining may be seen in benign endometrial tissue with tubal metaplasia, but strong, diffuse staining likely indicates HSIL or carcinoma. These findings can be helpful in interpreting hyperchromatic crowded groups in menstrual Pap specimens. Further study may be prudent, being aware of the small study group.

Diagnostic pitfalls of Hashimoto's/lymphocytic thyroiditis on fine-needle aspirations and strategies to avoid overdiagnosis.

OBJECTIVE: The importance of identifying papillary carcinoma or lymphoma amidst background Hashimoto's/lymphocytic thyroiditis (H/LT) is well documented. However, avoidance of overdiagnosing neoplasms on thyroid fine-needle aspiration (FNA) with only H/LT has not been adequately addressed. STUDY DESIGN: This study aimed to identify cytomorphologic features leading to overdiagnosing neoplasms within background H/LT. Nine thyroid FNAs classified as suspicious or positive for neoplasm with subsequent thyroidectomy specimens having only H/LT were identified. Cytologic features of these cases were compared to 8 control cases from the same time period and FNAs from both groups were reevaluated for features from the cytology literature. RESULTS: Features leading to overdiagnosing papillary carcinoma were: powdery chromatin, occasional nuclear grooves or holes, and paucity of background lymphocytes. One feature differentiating H/LT from neoplasm noted in most cases was lymphocytes infiltrating follicular groups. In contrast, true papillary carcinomas displayed characteristic features in multiple cell clusters. These clusters were devoid of infiltrating lymphocytes or displayed only rare lymphocytes at their periphery. A microfollicular pattern with paucity of background lymphocytes was the major pitfall in overdiagnosing follicular neoplasm. CONCLUSIONS: Features suspicious for neoplasm are often seen in FNA of H/LT, leading to unnecessary surgery. Recognizing this pitfall and its differentiating features should avert overdiagnosis.

Comparison of breast carcinoma prognostic/predictive biomarkers on cell blocks obtained by various methods: Cellient, formalin and thrombin.

OBJECTIVE: To compare results of immunohistochemical (IHC) assays for estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) performed on thrombin, formalin and Cellient cell blocks to those performed on tissue. STUDY DESIGN: Formalin, thrombin and Cellient cell blocks were prepared from cytologic samples obtained from resection specimens of 31 patients with invasive breast carcinoma. ER, PR, HER2 and MIB-1 (Ki-67) IHC stains were performed on all three types of cell blocks and compared to the same stains performed on the patient's paraffin-embedded biopsy or resection. Cell and tissue blocks with equivocal staining for HER2 were submitted for fluorescence in situ hybridization (FISH). RESULTS: Adequate Cellient blocks were obtained for all 31 cases. Comparison of results of ER IHC assays on all three types of cell blocks showed 100% correlation with tissue. Both Cellient and thrombin blocks showed 100% correlation with tissue for HER2 IHC and FISH results. The only statistically significant difference between cell block methods was found in PR staining, where false-negative results occurred with Cellient and thrombin blocks. CONCLUSION: Breast biomarker IHC assays performed on Cellient blocks are reliable and correlate with tissue block results, particularly for ER and HER2, the most clinically important markers.

S100P and XIAP expression in pancreatic ductal adenocarcinoma: potential novel biomarkers as a diagnostic adjunct to fine needle aspiration cytology.

OBJECTIVE: The usefulness of 2 novel biomarkers in pancreatic surgical and cytological specimens that could reliably differentiate non-neoplastic pancreatic duct and benign gut epithelium from pancreatic ductal adenocarcinoma (PDA) was evaluated. STUDY DESIGN: A total of 14 pancreatic resection specimens (RSs), 23 endoscopic ultrasound-guided fine needle aspirations (EUS-FNAs) of PDA and 8 benign pancreatic EUS-FNAs were selected. Twelve of 14 RSs had corresponding EUS-FNAs with cell blocks (CBs). Non-neoplastic pancreatic tissue, including chronic pancreatitis, was evaluated in all RSs. Immunohistochemical stains for S100P and X-linked inhibitor of apoptosis protein (XIAP) were performed on tissue and CB sections. Staining intensity (0 no staining; 1+ weak; 2+ moderate; 3+ strong) and proportion of positive cells (less than 10% negative; 1+ 10-25%; 2+ 26-75%; 3+ greater than 75%) were assessed. Positive staining was defined as ≥10% cells with at least 1+ intensity. RESULTS: The sensitivity and specificity of S100P and XIAP immunoreactivity for a diagnosis of PDA in RSs were both 100%. In contrast, the sensitivity and specificity in EUS-FNA CBs of S100P were 78.2 and 87.5% and of XIAP 82.6 and 50.0%, respectively. The combined sensitivity of S100P and XIAP was 100% in 12 RSs and 83.3% in the corresponding EUS-FNA CBs. CONCLUSION: Two novel biomarkers have very high sensitivity and specificity in the diagnosis of PDA in RSs. S100P has slightly lower sensitivity and higher specificity of PDA than XIAP in EUS-FNA specimens. We recommend using both biomarkers as cytological diagnostic adjuncts, especially in difficult cases of well-differentiated PDA versus reactive ductal epithelium.

Rescreening of high-risk HPV positive Papanicolaou tests initially screened as negative is a low yield procedure in the era of HPV genotyping.

INTRODUCTION: Many laboratories rescreen Papanicolaou test slides initially interpreted as negative, but positive for human papillomavirus (HPV) high-risk types, as a quality control measure. We have evaluated the utility of this practice in the era of HPV genotyping as a laboratory improvement project. MATERIAL AND METHODS: Between August 2016 and October 2019, we identified 3618 rescreened Papanicolaou tests with follow-up biopsies. The biopsy results were put into 3 groups: 1) Negative; 2) LSIL: HPV changes or low-grade squamous intraepithelial lesion; and 3) HSIL: high-grade squamous intraepithelial lesion or carcinoma. HPV molecular testing results with subtyping for types 16 and 18 were available for 3117 of these cases. RESULTS: A total of 530 of 2812 Papanicolaou tests (18.8%) with positive HPV results were reinterpreted as cytologically abnormal after rescreening; 75 (14.2%) had a biopsy result of HSIL. The subset positive for HPV types 16/18 had 38 of 133 cytology positive cases diagnosed as HSIL on biopsy vs. 107 of 935 cytology negative cases diagnosed as HSIL on biopsy (28.6% vs. 11.4%, P < 0.0001). The subset positive for "other" (non-16/18) high-risk HPV types had 37 of 397 cytology positive follow-up HSIL vs. 84 of 1288 cytology negative follow-up HSIL (9.3% vs. 6.5%, P = 0.075). CONCLUSIONS: Rescreening has the highest yield in specimens positive for types 16/18. However, for this group colposcopy is recommended regardless of cytology findings, reducing the patient benefit. Routine rescreening of cytology negative/HPV positive Papanicolaou tests has reduced utility when HPV subtyping is performed and should be reconsidered.

Diagnosis and typing of systemic amyloidosis: The role of abdominal fat pad fine needle aspiration biopsy.

INTRODUCTION: Systemic amyloidosis (SA) has a broad nonspecific clinical presentation. Its diagnosis depends on identifying amyloid in tissues. Abdominal fat pad fine needle aspiration (FPFNA) has been suggested as a sensitive and specific test for diagnosing SA. MATERIALS AND METHODS: Thirty-nine FPFNA from 38 patients (16 women and 20 men, age range 40-88 years) during a 15-year period were reviewed. Smears and cell blocks were stained with Congo red (CR). A panel of antibodies (serum amyloid protein, serum amyloid A, albumin, transthyretin, kappa light chain and lambda light chain) was used on six cell blocks from five patients. The FNA findings were correlated with clinical and histological follow-up. RESULTS: FPFNAs were positive, confirmed by CR in 5/39 (13%), suspicious in 1/39 (3%), negative in 28/39 (72%), and insufficient for diagnosis in 5/39 (13%) of cases. In all the positive cases, SA was confirmed within 2-16 weeks. Among the 28 negative cases, SA was diagnosed in 21, the rest were lost to follow-up. Among the insufficient cases, SA was diagnosed in four and one was lost to follow-up. Specificity was 100%, whereas sensitivity was 19%. SA typing using cell block sections was successful in three, un-interpretable in one, and negative in two cases. CONCLUSION: FPFNA for SA is not as good as previously reported. This may be due to different practice setting, level of experience, diagnostic technique, or absence of abdominal soft tissue involvement. A negative result of FPFNA does not exclude SA. Immune phenotyping of amyloid is possible on cell block.

Pathology Trainee Redeployment and Education During the COVID-19 Pandemic: An Institutional Experience.

Pathology training programs throughout the United States have endured unprecedented challenges dealing with the ongoing coronavirus disease 2019 pandemic. At Houston Methodist Hospital, the Department of Pathology and Genomic Medicine planned and executed a trainee-oriented, stepwise emergency response. The focus was on optimizing workflows among areas of both clinical and anatomic pathology, maintaining an excellent educational experience, and minimizing trainee exposure to coronavirus disease 2019. During the first phase of the response, trainees were divided into 2 groups: one working on-site and the other working remotely. With the progression of the pandemic, all trainees were called back on-site and further redeployed within our department to meet the significantly increased workload demands of our clinical laboratory services. Adjustments to trainee educational activities included, among others, the organization of a daily coronavirus disease 2019 virtual seminar series. This series served to facilitate communication between faculty, laboratory managers, and trainees. Moreover, it became a forum for trainees to provide updates on individual service workflows and volumes, ongoing projects and research, as well as literature reviews on coronavirus disease 2019-related topics. From our program's experience, redeploying pathology trainees within our department during the coronavirus disease 2019 pandemic resulted in optimization of patient care while ensuring trainee safety, and importantly, helped to maintain continuous high-quality education through active involvement in unique learning opportunities.

Bethesda 2014 Implementation and Human Papillomavirus Primary Screening: Practices of Laboratories Participating in the College of American Pathologists PAP Education Program.

CONTEXT.­: Cervical cancer screening laboratory practices may evolve with new terminology and technologies. OBJECTIVE.­: To investigate changes in cervical cytopathology practice resulting from the 2014 Bethesda System updates and screening technologies. DESIGN.­: Questionnaires accompanied 2016 and 2017 mailings of the College of American Pathologists PAP Education program. RESULTS.­: In 2016, most laboratories surveyed had adopted or were planning to adopt 2014 Bethesda System updates, and the majority (53%; 365 of 689) used an age cutoff of 45 for reporting benign-appearing endometrial cells. However, 51.3% (354 of 690) of laboratories used the term low-grade squamous intraepithelial lesion, cannot exclude high-grade squamous intraepithelial lesion, for cases with indeterminate features, and 44.9% (298 of 664) of laboratories used a 5000-cell cutoff for minimum squamous cellularity for posthysterectomy and posttherapy specimens. Reporting rates for cervical cytology metrics changed very little from 2013 to 2016, and the median ratio of atypical squamous cells to squamous intraepithelial lesion cases was 1.9 for ThinPrep and 1.8 for SurePath preparations. Most laboratories (59.4%; 389 of 655) did not offer stand-alone primary human papillomavirus (HPV) testing in 2017, and primary HPV testing accounted for a low proportion of HPV testing volumes. The Roche Cobas method was the most common platform for HPV primary screening. CONCLUSIONS.­: These questionnaire surveys provide data about the current status of cervical cytology screening, including changes related to the 2014 Bethesda System updates and the adoption of HPV primary screening techniques.

Age-specific 3-year cumulative risk of cervical cancer and high-grade dysplasia on biopsy in 9434 women who underwent HPV cytology cotesting.

BACKGROUND: High-risk human papillomavirus (HPV)-Papanicolaou (Pap) cotesting is recommended for cervical cancer screening in women aged ≥30 years. The current study analyzed the effectiveness of cotesting on risk management in different age groups. METHODS: A retrospective review of a 5-year cytology database identified 9434 women with HPV-Pap cotesting and follow-up cervical biopsy. The 3-year cumulative risk of developing high-grade cervical lesions (≥high-grade squamous intraepithelial lesion [HSIL]) was analyzed using age stratification. RESULTS: The 3-year cumulative risk of developing ≥HSIL was found to be significantly different in women with baseline cotesting HPV-positive and Pap-positive results (HPV+/Pap+; defined as ≥atypical squamous cells of undetermined significance), HPV+ and Pap-negative results, and HPV-negative and Pap+ results at 19.2%, 7.9%, and 3.1%, respectively (P < .001). The risk of ≥HSIL peaked at ages 30 to 39 years and significantly decreased at ages 50 to 59 years (16.6% vs 6.7%; P < .001). Women aged <30 years shared a high risk similar to that of women aged 30 to 39 years (17.3% vs 16.6%; P = .52), and risk stratification by cotesting was found to be equally effective in the younger age group (HPV+ and Pap+: 19.6%; HPV+ and Pap-negative: 7.2%; and HPV-negative and Pap+: 4.4% [P < .001]). CONCLUSIONS: High-risk HPV-Pap cotesting appears to be extremely sensitive for the prediction of the risk of developing ≥HSIL and is an effective tool for risk stratification. In the current study, the 3-year cumulative risk of developing ≥HSIL varied significantly with age, with the highest risk noted among women aged <40 years and the lowest risk observed in women aged 50 to 59 years. Pap testing significantly impacted risk stratification in the HPV+ positive group, especially in women aged <60 years. Women aged <30 years were found to have a risk profile and cotesting efficacy similar to those of women aged 30 to 39 years. Modification of the current recommendation to offer cotesting to women aged ≥30 years might be considered to include those patients aged <30 years.

HPV status in women with high-grade dysplasia on cervical biopsy and preceding negative HPV tests.

INTRODUCTION: A considerable number of patients with high-grade cervical lesions have undergone preceding human papillomavirus (HPV) tests with negative results. In the present study, we attempted to elucidate the factors potentially contributing to the findings by testing biopsied samples from these patients. MATERIALS AND METHODS: Of the 1654 women with HPV testing and follow-up cervicovaginal biopsies from March 1, 2013 to June 30, 2014, 21 of 252 women (8.3%) with biopsy-confirmed high-grade squamous intraepithelial lesion (HSIL) or worse had had negative results from preceding high-risk (hr)HPV tests. The corresponding paraffin blocks were tested for HPV using the Cobas 4800 system, a DNA microarray against 40 HPV genotypes, and DNA sequencing. RESULTS: HPV was detected in 20 (95%) of the 21 biopsies with HSIL or worse, including HPV16/18 in 4, non-16/18 hrHPV in 10, and non-hrHPV in 6. HPV59 and HPV45 were 2.2 times more frequently detected than HPV16/18 in these samples. One sample was negative for all 3 tests (5%). CONCLUSIONS: Our study has demonstrated that 8.3% of women with biopsy-confirmed HSIL or worse had preceding test results that were negative for hrHPV. The vast majority of the biopsied samples had detectable HPV, primarily hrHPV genotypes (67%) with HPV59 and HPV45 predominance. This genotypic prevalence pattern was markedly different from those reported in the general population. Non-hrHPV genotypes contributed to 29% of the cases, and HPV-negative cases were rare. In addition to the limited Cobas testing panel and rare possible HPV-negative HSIL or worse, other possible contributing factors to the discrepancy include cytologic sampling, interference material, technical errors, and reduced L1 gene expression in high-grade lesions.

Morphologic, patient and interpreter profiles of high-risk human papillomavirus-positive vs.-negative cases of atypical squamous cells of undetermined significance.

OBJECTIVE: To define the morphologic and patient profiles, if any, that distinguish high-risk human papillomavirus (HR-HPV)-positive atypical squamous cells of undetermined significance (ASCUS) from HR-HPV-negative ASCUS and to compare individual and laboratory reporting rates with the national averages. STUDY DESIGN: One hundred fifty liquid-based cervicovaginal preparations (ThinPrep, Cytyc Corporation, Boxborough, Massachusetts, U.S.A.) with a diagnosis of ASCUS and a reflex HR-HPV test were assessed for the following features: background patient information, cell morphology, cell patterns and interpreter profiles. Fisher's Exact test (2-tailed) was used to calculate the exact probability of obtaining results by chance. RESULTS: The median age of the HR-HPV-positive patients was approximately 11 years younger than the HPV-negative group, and pregnant patients were also more apt to be HPV positive. Atypical cells in greater numbers and in groups as opposed to single cells correlated more often with HR-HPV-positive individuals. Koilocytelike changes and parakeratosis were more frequently associated with HR-HPV, but the presence of Trichomonas was usually a negative predictor. CONCLUSION: In cases diagnosed as ASCUS, there are certain cytologic features and patient types that are more likely to be associated with HR-HPV positivity. This could be used in everyday practice to further fine tune the diagnosis of ASCUS. Monitoring individual and laboratory ASCUS rates with HR-HPV positivity can be an important quality improvement indicator.

Performance of Roche cobas high-risk human papillomavirus (hrHPV) testing in the two most common liquid-based Papanicolaou test platforms.

INTRODUCTION: High-risk human papillomavirus (hrHPV) testing is important in cervical cancer screening and management algorithms. Roche (Pleasanton, Calif.) cobas hrHPV testing is commonly performed on both ThinPrep (TP) and SurePath (SP) samples, but performance of these platforms has not been fully investigated in the literature. MATERIALS AND METHODS: Roche hrHPV testing was performed on 47,885 (TP = 18,295; SP = 29,590) out of 130,648 consecutive Papanicolaou tests, over 16 months; 1895 of those had interpretable biopsies. RESULTS: The overall hrHPV detection rates were similar in TP (13.5%) and SP (13.1%). The hrHPV positive rate was higher in SP (8.5%) than TP (7.3%, P < 0.0001) in women with negative cytology; the difference in other cytologic diagnosis categories was insignificant. TP samples had significantly fewer negative cytology diagnoses (7.3% versus 8.5%, P < 0.0001), more low-grade abnormalities in cytology and biopsies, and higher colposcopy referral rate (4.8% versus 2.7%, P < 0.0001) than SP. There were no differences between TP and SP in detecting ≥HSIL by hrHPV testing, cytology or biopsy. SP samples had a significantly higher rate of HPV 16/18 but a lower rate of non-16/18 hrHPV genotypes than TP. CONCLUSIONS: Roche cobas hrHPV testing was similar in both TP and SP platforms. The significantly lower hrHPV detection rate in cytological negative TP samples is likely related to higher cytology reporting rates for indeterminate and low-grade diagnoses in TP than SP samples. Significant differences were also observed in hrHPV genotyping results between TP and SP. Clinical risk stratification based on hrHPV testing may need to take testing platforms into consideration.

Do Infection Patterns of Human Papillomavirus Affect the Cytologic Detection of High-Grade Cervical Lesions on Papanicolaou Tests?

CONTEXT: - Persistent infection with high-risk human papillomavirus (hrHPV) is the major cause of cervical cancer. The effect of HPV infection patterns on cytologic detection of cervical lesions is unknown. OBJECTIVE: - To determine the effect of HPV infection patterns on the sensitivity of cytologic detection of high-grade cervical lesions. DESIGN: - Papanicolaou tests from 257 women with biopsy-confirmed, high-grade squamous intraepithelial lesions were analyzed with respect to HPV infection patterns. RESULTS: - Among 257 biopsy-confirmed, high-grade squamous intraepithelial lesion cases, the preceding cytology showed 20 cases (8%) were benign; 166 cases (65%) were low-grade cervical lesions, including atypical squamous cell of undetermined significance and low-grade squamous intraepithelial lesions; and 71 cases (28%) were high-grade cervical lesions, including atypical squamous cells cannot rule out high-grade squamous intraepithelial lesion (atypical squamous cell-high), atypical glandular cells, and high-grade squamous intraepithelial lesions. In 236 cases tested for HPV, those exhibiting low-grade cervical lesions on cytology were often associated with coinfections of mixed hrHPV genotypes (31 of 40; 78%) or non-16/18 hrHPV (75/103; 73%), compared with single-genotype infections of HPV-16 (33 of 62; 53%) or HPV-18 (2 of 6; 33%) ( P = .001). In contrast, high-grade cervical lesion cytomorphology tended to associate with the single-genotype infection of HPV-16 (20 of 62; 32%) or HPV-18 (3 of 6; 50%), compared with non-16/18 hrHPV (25 of 103; 24%) or multigenotype infection (8 of 40; 20%) ( P = .01). CONCLUSIONS: - Our findings suggest that multigenotypic or non-16/18 hrHPV infections often produce deceptive lower-grade cytomorphology, which could result in underdiagnosis and delay of treatment. The HPV infection patterns may offer unrecognized benefit beyond HPV genotyping and should be considered during clinical risk evaluation of women with lower-grade cytology.

Negative Pap tests in women with high-grade cervical lesions on follow-up biopsies: Contributing factors and role of human papillomavirus genotyping.

BACKGROUND: Previous studies have indicated that negative Papanicolaou (Pap) tests can precede high-grade cervical lesions (HGCL) on biopsy. This study aims to determine the contributing factors for cytologic discrepancy and the potential role of human papilloma virus (HPV) testing in risk evaluation of women with negative Pap tests. METHODS: Of 42,797 Pap tests interpreted as negative for intraepithelial lesion or malignancy (NILM) from March 1, 2013 to December 30, 2014, 426 had available HPV testing and follow-up biopsy. The NILM Pap tests with biopsy-confirmed HGCL were reviewed. RESULTS: Among 426 cytology-negative cases, the biopsies showed benign histology in 243 (57%), low-grade squamous intraepithelial lesion in 157 (37%), HGCL in 22 (5%), and endometrial adenocarcinoma in 4 (1%) cases. The sensitivity/specificity/positive predictive values (PPV) of high-risk HPV (hrHPV) and HPV16/18 tests in predicting HGCL was 91%/45%/8% and 55%/76%/11%, respectively. Upon review of NILM Pap tests with biopsy-confirmed HGCL, the contributing factors to negative cytology included absence of abnormal cells (12/21, 57%) or diagnostic high-grade cells (6/21, 29%), unsatisfactory samples (2/21, 10%), and interpretation variances (1/21, 5%). Interpretation variances in three high-risk lesions (1 HSIL, 2 ASC-H) were influenced by marked obscuring inflammation. CONCLUSIONS: Our study demonstrated that 5% of women underwent co-testing with negative Pap tests had HGCL on follow-up biopsy. Absence of diagnostic cells was the leading cause for cytology discrepancy and interpretation variances were influenced by marked obscuring inflammation. HPV testing and genotyping had limited value in risk stratification due to extremely low PPV. Focused rescreening of hrHPV-positive NILM with obscuring factors may help reduce interpretation variances.

Aberrant staining with Grocott's methenamine silver: utility beyond fungal organisms.

INTRODUCTION: Historically, Grocott's methenamine silver (GMS) stain has been used in cytopathology to highlight Pneumocystis jiroveci and other fungal organisms. Several nonfungal organisms, however, can show distinct GMS staining patterns that are important to recognize. MATERIALS AND METHODS: We prospectively and retrospectively identified nonfungal pathogenic organisms on GMS-stained liquid-based and cytospin preparations of respiratory cytologic specimens. The organisms included parasitic worms, viruses, and assorted bacteria. Nine cases were identified, including two cases each of Strongyloides stercoralis, Cytomegalovirus, Mycobacterium tuberculosis, Nocardia species, as well as one case of anthrax-like Bacillus cereus. RESULTS: The nonfungal organisms had silver deposition in varying locations including the internal organs and/or cuticle of Strongyloides stercoralis larvae, the intranuclear inclusions of Cytomegalovirus infected cells, the surfaces of partially acid-fast Nocardia species and acid-fast Mycobacterium tuberculosis, and the cell walls and central endospores of Bacillus cereus. In 3 of the 9 cases, organisms were not clinically suspected. It was the aberrant GMS staining that pointed to the diagnosis and led to the performance of the definitive stain, culture, or other test. CONCLUSIONS: GMS is a chromic acid, sodium bisulfate stain that precipitates silver ions in fungal polysaccharide walls, producing the characteristic black stain on light microscopy. It is helpful to recognize aberrant GMS staining to avoid misdiagnosis of fungal elements. GMS stains several nonfungal human pathogens and may be a particularly useful diagnostic aid when the infectious condition is not clinically suspected or the number of organisms is sparse and otherwise difficult to visualize by routine staining methods.

Performance of Aptima and Cobas HPV testing platforms in detecting high-grade cervical dysplasia and cancer.

BACKGROUND: Human papillomavirus (HPV) tests and genotyping have been used in clinical risk assessment. The purpose of this study was to analyze the performance of 2 common HPV testing platforms in detecting high-grade cervical lesions (high-grade squamous intraepithelial lesion [HSIL] or worse [≥HSIL]). METHODS: Between January 1 and December 31, 2015, 2041 Papanicolaou (Pap) tests with biopsy confirmation were analyzed along with HPV tests performed on Cobas or Aptima platforms. A biopsy diagnosis of grade 2 cervical intraepithelial neoplasia was confirmed with p16/Ki-67 immunohistochemistry. RESULTS: In total, 1866 and 175 Pap cases were tested on Cobas and Aptima platforms, respectively. Both platforms were highly sensitive (97% for both) for biopsy-confirmed ≥HSIL. Cobas HPV testing had higher positive rates for the diagnosis of benign lesions (84% vs 51%) and low-grade squamous intraepithelial lesions (89% vs 63%) on biopsy compared with Aptima. Aptima testing had significantly higher specificity for ≥HSIL than Cobas (41% vs 13%; P < .0001). Overall, performance of the Aptima platform was superior to that of the Cobas platform in detecting biopsy-confirmed ≥HSIL, resulting from its significantly higher positive predictive value (25% vs 16%; P < .03) and overall accuracy (50% vs 26%; P < .0001). CONCLUSIONS: Although both the Cobas and Aptima platforms offer highly sensitive tests for high-grade cervical lesions, Aptima HPV testing demonstrated significantly higher specificity and positive predictive value than Cobas testing for biopsy-confirmed ≥HSIL. The considerable difference may be related to the significant increase in E6/E7 expression after HPV DNA integration. The significantly higher specificity and overall accuracy of Aptima testing for ≥HSIL, resulting in the identification of high-risk populations that require immediate treatment and close follow-up, may prove useful in clinical risk stratification. Cancer Cytopathol 2017;125:652-7. © 2017 American Cancer Society.