Revisão da citologia na reunião da EMD

Seja qual for o cenário, a convicção do colposcopista ou do ginecologista e sua confiança no relatório de citologia dependem da sensibilidade e valor preditivo positivo (VPP) nesse laboratório e seu controle de qualidade.

  • Cytology slide review allows potential false positive features to be recognised before treatment is carried out.
  • Equivocal cytology reports may be given more definitive reports on review allowing the correct treatment to be carried out.
  • Definitive cytological features may be presented and confirmed at MDT meetings allowing treatment to be planned even when the lesion cannot be seen at colposcopy.
  • False negative cytology may be presented and discussed during the historical review of slides reported before a diagnosis of cervical cancer.
  • Review of equivocal cases and recognised pitfalls provides colposcopists and other professional groups with insight into difficult areas of cytology.
  • High-risk HPV positivity may support a diagnosis of HSIL or CIN but does not confirm it; nor does high-risk HPV negativity refute it.

 

Figure 12.1. Potential pitfalls to be reviewed at MDT meeting 

(a) Reported as moderate dyskaryosis (HSIL) on cytology.
(b) Histology from the same case reported as CIN2.

 

However, the diagnosis of CIN2 was doubted when this case was reviewed as a teaching case several years later and most likely represents immature metaplasia. It would now be resolved by p16/Ki67 staining (see below).

A decision to carry out a LLETZ was based on colposcopic appearances as well as the cytology report and is typical of cases requiring multidisciplinary discussion.


Hyperchromatic crowded cell groups

The diagnosis of HSIL in Figure 12.2 was confirmed as CIN3 but represents a difficult diagnosis warranting MDT discussion alongside full slide review and presentation of other findings. 

 

Figure 12.2   This image is reproduced from the BSCC Terminology Conference 2002 and is also shown in Chapter 10 - Pitfalls in cytology as an example of HSIL seen in a hyperchromatic crowded cell of groups.  Less than half of the respondents recognised this image as HSIL. 

 

Alternatively, such changes could be seen when previous negative or atypical slides are reviewed from a patient who subsequently develops HSIL or cancer. 

Hyperchromatic crowded cell groups are known to be at risk for a false negative diagnosis in conventional smears and liquid-based preparations (Demay 2000; Gupta et al. 2013). 

This cell group could be misinterpreted as a cluster of endocervical cells - but close review shows severely dyskaryotic cells at the edge of the group of cells; similar cells are likely to be found on careful search of the rest of the slide.

 

Definitive cytological diagnoses confirmed at MDT meeting

Classic appearances of HSIL and AIS respectively may have been well represented on the cytology slides even if not widespread, reported unequivocally and confirmed on review. 

Colposcopy may be negative in such cases, particularly if the lesion is high in the endocervical canal: a biopsy may be inadequate or negative.  Glandular abnormalities are known to be difficult to identify and sample at colposcopy.

Diagnostic LLETZ may be considered in such cases even if a punch biopsy does not identify the lesion.

Figure 12.3. (a) Unequivocal HSIL.
Figure 12.3. (b) Typical AIS

 

 

Revisão de citologia para reuniões da EMD

  • Revisão de lâminas por citologistas experientes e apresentação de resultados em uma reunião de EMD permite que um caso de apresentação citológica difícil seja reavaliada e confirmada ou revisada
  • As armadilhas diagnósticas conhecidas devem ser reavaliadas à luz de outros parâmetros, com os membros da equipe compreendendo os dilemas e as dificuldades
  • Os diagnósticos confirmados de LIEEAG - HSIL (favorecendo NIC3) ou AIS / Adenocarcinoma podem ser aceitos na ausência de lesões visíveis na colposcopia, especialmente se for confirmado em múltiplas células ou grupos celulares

 

X