A tale of atypia: What can we learn from this?

Abstract

In a sterile, cold doctor's office, I was sitting opposite from a 37-year-old woman who had come in for her first ever Papanicolaou test, which was being offered as a part of our free cervical cancer screening program.I was holding her pathology report, on which the words "ATYPICAL SQUAMOUS CELLS (ASC-US)" were typed. I tried to explain to her what the Papanicolaou test was all about and what "ASC-US" could mean in terms of disease and, more importantly, what it most likely was not. I could see the anxiety, bewilderment, and confusion in her eyes. "So I have cancer?" she asked: surely atypical meant that it was not typical and that her diagnosis was bad. This was the first time that I had personally experienced this patient reaction to the word atypical first hand, but I am sure that our clinicians have this conversation routinely with their patients, witnessing similar anxiety in many of them.Furthermore, in this new era of pathology web portals, where pathology reports are becoming freely available to patients online, I can only imagine the apprehension of patients who pull their report and try to understand what we mean by atypical in their pathology report. After doing a internet search to find out what this mysterious disease might be and how it would affect them, they will find that the first hit is "Atypical Cells: Are They Cancer?," which, I am certain, is not very comforting.One of the major attributes of physicians should be the skill to empathize with, understand, and help patients. Therefore, as pathologists, we should strive to make our reports as clear and unequivocal as possible. This could ultimately prevent or minimize confusion and anxiety in both providers and patients and, we hope, prevent overtreatment of patients. In this issue of Cancer Cytopathology, VandenBussche et al 1 provide us with an introspective review of their institutional urothelial atypia rate over a 20-year span, which makes us ponder how we can do better. The stated primary goals of the Paris System for Reporting Urine Cytology (TPS) 2 were to refocus the emphasis of urine cytology on high-grade urothelial carcinoma (HGUC), to develop diagnostic categories with standardized definitions, and to increase the credibility of urine cytology. Not only did urinary cytology have low sensitivity for relatively indolent low-grade urothelial neoplasms, but it was also afflicted by an up to 50% rate of indeterminate diagnoses, 3 with a very low positive predictive value for malignancy. Faced with an almost coin-flip probability of having a diagnosis of atypical, urologists even called for abandoning urinary cytology altogether. 4Our daily experience shows that we cannot completely eliminate the diagnosis of atypia: it continues to be a useful category for filling the gap between what is recognizable as normal (or at least a version of normal) and what is recognizable as unequivocally abnormal. It still holds true that this diagnosis should be used sparingly. It cannot be overstressed that the potential overuse of atypia diagnoses can l...

Cytologic diagnosis of “atypical” in serous fluid cytopathology. Approach of the international system for reporting serous fluid cytopathology

“…Future studies should help to refine acceptable ROM rates for AUS. In addition, intra‐laboratory monitoring of the AUS rate, which we recommend, may play a role in avoiding overuse of this diagnostic category 10,11 …”

The Paris System for reporting urinary cytology in daily practice with emphasis on ancillary testing by multiprobe FISH

“…The prevalence of the diagnosis ‘atypia’ depends on many factors, some of which are related to the biology of the lesion (eg, inflammatory atypia, cytology from the UUT), but also the experience of the cytologist or the urologist performing the cystoscopy. Also the sampling method has an influence on the interpretation, as voided urine specimens naturally are less cellular but contain a higher proportion of cells with degenerative appearance compared with bladder washings, which may hamper cytological evaluation 3 6. Cytological diagnosis of LGUN was rare (0.1%), which is due to the stringent TPS criteria requiring true papillae.…”

“…Before TPS, the term ‘atypia’ was poorly defined and therefore inconsistently used in the differential diagnosis of reactive changes, LGUN and HGUC, resulting in a wide interobserver and intraobserver variability 5. Several other reasons that can affect the morphological evaluation leading to the diagnosis of equivocal atypia in urinary cytology were summarised recently 6. The TPS category AUC, most importantly, should be restricted to cases, where HGUC cannot be excluded.…”

Significance of hepatocyte atypia in liver fine needle aspiration

“…As noted in a review by Pambuccian, the term atypia is intimately associated with the practice of cytopathology; at the same time, it conveys little useful information to clinicians unless used in a standardized reporting system with clear clinical (risk of malignancy) and management implications 109 . Overuse of atypia can result in clinicians misinterpreting the pathology report, losing confidence in the diagnostic value of cytopathology, and subsequent excessive testing, at the detriment of patient satisfaction and well‐being and increasing health care costs 109,110 …”