Should LSIL‐H be a distinct cytology category?

Abstract

BACKGROUND: The 2001 Bethesda System for gynecologic cervical cytology reporting classifies squamous intraepithelial lesions into low‐grade (LSIL) and high‐grade (HSIL) lesions. An intermediate term, “low‐grade squamous intraepithelial lesion, cannot exclude high‐grade squamous intraepithelial lesion (LSIL‐H),” has been used in a small percentage of LSIL cases. To the authors' knowledge, little is known regarding the human papillomavirus (HPV) status in patients with LSIL‐H. METHODS: A total of 808 SurePath specimens obtained between December 2009 and April 2011 were tested for 40 HPV genotypes using DNA microarray, followed by a confirmatory DNA sequencing assay. RESULTS: The infection rate for high‐risk HPV in women with LSIL‐H (92%) was strikingly close to that for women with HSIL (91%), which was higher than that for those with LSIL (74%); atypical squamous cells, cannot rule out high‐grade lesion (ASC‐H) (78%); or LSIL and ASC‐H combined (74%). HPV type 16, the most common carcinogenic HPV genotype, was detected in 36% of women with LSIL‐H, which was significantly higher than that in women with LSIL and ASC‐H combined (13.8%), but less than that in women with HSIL (44.6%). Patients with LSIL‐H and HSIL had similar infection rates for low‐risk/intermediate‐risk HPV genotypes, which were lower than those in LSIL or LSIL and ASC‐H combined. CONCLUSIONS: Women found to have LSIL‐H on a Papanicolaou test appear to have a unique HPV distribution pattern that clearly differs from LSIL and is comparable to that for HSIL, suggesting an increased risk of high‐grade lesions over that of women with LSIL. Recognizing LSIL‐H as an independent diagnostic category may help in the early identification of the high‐risk subgroup that may require a management algorithm comparable to that for patients with HSIL. Cancer (Cancer Cytopathol) 2012. © 2012 American Cancer Society.

Low‐grade squamous intraepithelial lesion, cannot rule out high‐grade lesion: Diagnosis, histological outcomes and human papillomavirus results

“…Owens et al found a higher prevalence of hrHPV in LROH (100%) compared with ASC‐H (59%). Similarly, Shidham et al reported 94% positivity for hrHPV for LROH/LSIL‐H (34/88) cases; Zhou et al also found the prevalence of hrHPV in LROH (92%), closer to HSIL (91%), when compared to LSIL (74%) and ASC‐H (78%). Barron et al reported hrHPV testing in 496 patients with LROH with a 90.5% positive rate, lower than HSIL (95.7%) and higher than ASC‐H (54.3%).…”

“…This terminology reflects the understanding of human papillomavirus (HPV) infection, the biological differences between these lesions and the significant impact on patient management. According to the 2014 American Society for Colposcopy and Cervical Pathology consensus guidelines, women with HSIL are treated with colposcopy and diagnostic excisional procedures, such as loop electrocautery excision procedure or cervical conisation; on the other hand, management of LSIL varies from repeat cytology/HPV cotesting to colposcopy, depending on factors such as age, pregnancy and HPV status …”

“…It has been proposed that these intermediate morphological patterns might be better designated with a diagnostic term that better conveys these findings. Many terminologies have been used, such as LSIL, cannot exclude HSIL (LSIL‐H), LSIL cannot rule out high‐grade lesion (LROH), LSIL with ASC‐H , LSIL with rare atypical cells suggestive but not diagnostic of HSIL , LSIL with an additional note alerting the provider to the presence of cells suggestive of HSIL , among others . However, this intermediate category is not part of the TBS 2014 reporting system and its use is discouraged.…”

“…Several reported studies have indicated that patients with LROH/LSIL‐H appeared to have an intermediate risk of harbouring or developing high‐grade squamous lesions on biopsy and a different HPV prevalence compared with LSIL and ASC‐H, ranging from 22.8% to 59% of cases . Because of the increased incidence of high‐grade lesions found on histology, comparable to patients with HSIL, it has been proposed that these patients may require a clinical management similar to HSIL diagnosis …”