Squamous atypia in the atrophic cervical vaginal smear

Abstract

BACKGROUND Squamous atypia in postmenopausal (PM) cervical vaginal smears (CVS) only rarely is associated with a biopsy‐proven squamous intraepithelial lesion (SIL), and thus most commonly represents an atrophy‐associated benign reactive change. METHODS To distinguish atypical squamous cells of undetermined significance (ASCUS) and SIL from atrophy‐associated benign reactive changes, a review of atypical atrophic PM CVS was performed. Ninety CVS exhibiting an atrophic smear pattern were considered appropriate for study. Repeat smears and/or biopsy after local estrogen therapy were requested to distinguish atrophic/reactive from dysplastic changes. RESULTS Generally, atrophic CVS exhibit uniform nuclear enlargement in the squamous cell population, which, using the criterion of nuclear enlargement alone, would qualify the majority of these cases to be classified as ASCUS. The nuclear enlargement associated with atrophy resolves with the local application of estrogen. Follow‐up after local estrogen treatment was available for 84 of 90 patients and revealed 10 cases of SIL (12%) and 9 cases of ASCUS (11%), 6 of which were favored to be of a reactive etiology. Nuclear features most commonly noted in the cases considered to be ASCUS (nonreactive) and SIL were nuclear hyperchromasia and nuclear contour irregularities. CONCLUSIONS Nuclear enlargement alone is not sufficient for diagnosing ASCUS or SIL in PM CVS. Nuclear enlargement in squamous cells is an expected normal reactive change present in PM CVS that resolves with the application of local estrogen. Nuclear hyperchromasia and irregular nuclear contours remain the most reliable cellular characteristics for diagnosing SIL in atrophic CVS. [See editorial on pages 200‐1, this issue.] Cancer (Cancer Cytopathol) 1998;84:218‐225. © 1998 American Cancer Society.

Diagnosis of ?ASCUS? in women over age 50 is less likely to be associated with dysplasia

“…Strictly using the criterion of nuclear enlargement, many of these cases are probably misclassified as ASCUS. Abati et al 19 recommended that nuclear hyperchromasia and irregular nuclear contours may be used to more rigorously and accurately diagnose SIL in postmenopausal smears.…”

“…One study attributes this decrease to the inexactness of the criteria for ASCUS. 19 However, these studies still promote close clinical follow-up of these patients due to the fact that the frequency of a precancerous lesion was in the 10 -20% range. The fact that ASCUS appears to have a different predictive value in the older population raises the possibility that it should be managed differently.…”

The borderline cervical smear: colposcopic and biopsy outcome

“…13th world congress of academic and environmental pathology, Nice, 1998). [25][26][27] Smears from these women are usually air dried and show apparent nuclear enlargement, a pronounced inflammatory component, and clusters of small dark bare nuclei that are diYcult to interpret. A helpful means of assessing atrophy related atypia is the "oestrogen test", whereby application of local oestrogen cream results in maturation of the squamous cells and easier interpretation of the cell morphology.…”

Diagnostic role of p16/INK4A protein in Human Papillomavirus (HPV) induced cervical dysplasia

“…Nevertheless, the ASC-H category seems problematic, since the morphologic difference in the appearance of a single metaplastic and/or neoplastic cell is not always clear and opens the way to false positive as well as false negative diagnoses [63][64][65]. Abati et al [66] stressed that nuclear hyperchromasia and irregular nuclear membrane contours count for the most reliable diagnostic feature of so-called pre-neoplastic atypia (possibly corresponding to the dysplastic cells in histological sections). In most uncertain cases, a short course of local estrogen cream therapy followed by repeated PAP tests was suggested as helpful [67].…”