Gynecologic Cytology-Histology Correlation Guideline
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1 Gynecologic Cytology- Correlation Guideline George G. Birdsong, MD and Joe W. Walker, Jr., MS, SCT(ASCP) CM Clinical Practice Committee Dr. Birdsong and Mr. Walker are grateful for extensive input from other members of the Clinical Practice Committee. George G. Birdsong, MD Joe W. Walker, Jr., MS, SCT(ASCP) CM Correlation of cytology with corresponding histologic specimens is one of the most informative and beneficial quality assurance practices. Abnormal Pap tests can be correlated with follow-up biopsies, which allows positive predictive value (PV+) to be calculated. 1 Negative Pap tests preceding histologically proven squamous intraepithelial lesions (SILs) of the cervix present potential educational opportunities for both the cytotechnologist and cytopathologist when there are screening or interpretive errors, and for the entire patient care team when there are sampling errors. Negative Pap tests that precede histologically proven SILs cannot be used to compute negative predictive values or sensitivity because biopsies are not routinely taken following negative Pap tests. 2 Time intervals between the cytologic and histologic specimens should be specified, and ideally limited to approximately six months to avoid non-correlation due to regression of lesions; however exact time interval limits should be determined by individual laboratories with consideration given to the percentage of follow-up biopsies submitted within various time intervals and the level of abnormality of the corresponding Pap tests. 1,3 Episodes of care that encompass multiple visits may produce multiple Pap tests and biopsies, so careful consideration should also be given to which of these to include in statistical calculations. Pap tests taken at colposcopy may or may not represent the performance of Pap tests taken for screening, and Pap tests taken more than 6 months prior to colposcopy may show a weaker correlation with histology than Pap tests taken within six months. The optimal time frame for correlating a biopsy with a Pap test diagnosed as SIL is 60 days. For quality assurance purposes, 100 days and up to 365 days may be more appropriate. 3 Pertinent components of a cytologic-histologic correlation protocol include the following: 1. Inclusion Criteria: a. Criteria for inclusion of cases, including the minimum/maximum time intervals between cytology specimens and histology specimens. 2. Protocol for when correlations are performed and by whom: a. At the time of histology sign-out (real-time) b. Periodic, retrospective correlation at defined intervals (i.e. monthly, quarterly, bi-annually). i. Real-time correlations facilitate comprehensive evaluations of the material available for a case, leading to a more useful report for the clinician and patient. However, they are an additional step which may slow down the sign out process. ii. Retrospective correlations may be more convenient for laboratory personnel since it allows a more narrow focus on the task. It is greatly facilitated by a laboratory information system (LIS) module expressly designed for the purpose. 3. Search Logistics: a. Grid or algorithm for assessing the correlation of the two specimens: i. Depending on the capabilities of the LIS, the initial portion of the process may be partially automated. For example, many if not most LISs are capable of generating a list of cytology-histology pairs in which the cytologic specimen precedes the histologic specimen within a defined time frame. In addition, many if not most modern LIS utilize canned comments for cytology reporting, and this data is stored VIII
2 Episodes of care that encompass multiple visits may produce multiple Pap tests and biopsies, so careful consideration should also be given to which of these to include in statistical calculations. in a database (as opposed to a text document). If the histologic diagnosis is also coded (for example, with SNOMED codes) and stored in a database, the LIS may able to perform the task of juxtaposing the cytology and histology specimens and making a preliminary determination of whether or not the specimens correlate. ii. Optionally, the data may be subdivided by results of ancillary molecular studies such as human papillomavirus (HPV) testing and p16 immunohistochemical staining. This information may be informative for quality assurance purposes, but it is not a required part of the process. If including HPV testing, one should specify the assay that is used. 4. Correlation Definitions: a. Definitions for correlating and non-correlating specimens with gradations in between if deemed appropriate. b. For example, a discrepancy could be classified as a major (2 step difference between Pap and biopsy result) or minor (1 step difference between Pap and biopsy result.) While some variation across laboratories in assessment of the correlation of cytology and corresponding histology specimens is inevitable, particularly regarding abnormalities less than HSIL, most laboratories would agree that a high-grade SIL (HSIL) in one modality paired with a negative result in the other modality constitutes a major discrepancy. More variation across laboratories in assessment of, for example, an ASC- US Pap and a corresponding biopsy read as negative or LSIL is to be expected, and there are no universally agreed upon standards for this process Tabulation of Data/Calculated parameters: a. A system for tabulating the data (i.e. spreadsheet, database program, specific LIS module, etc.) should be defined. b. Parameters to be calculated (i.e. percentages of pairs with exact agreement, minor disagreement, major disagreement, etc.) c. PV+ The output of this process can optionally be further enhanced by the creation of histograms depicting the number of cytology-histology pairs with exact agreement, minor overcalls and undercalls, and major overcalls and undercalls. This could be further sub-divided for each cytologic or histologic diagnosis, but pairs in which at least one of the specimens is HSIL or greater are most important clinically. Individual laboratories should determine the most appropriate system for themselves. 6. A defined procedure for investigation/evaluation of non-correlating specimen pairs a. Definition of false positive (FP) b. Definition of false negative (FN) c. Pick list of common explanations for FP and FN major discrepancies (i.e. sampling, screening, difference of opinion, HPV (+), overcall, under call, etc.) 4 7. Statistical Calculations: a. Establish criteria for expected PV+ within the laboratory. While there are no universally agreed upon benchmarks for PV+, several studies which provide this parameter have been published or have presented data from which it may be calculated. 5-8 PV+ rates vary from approximately 60% to >95% in these studies. The rates are not directly comparable between studies because the details of the correlation protocols may vary. The Royal College of Pathologists of Australia has set a standard of 65% for the PV+ of HSIL. 9 Other parameters such as the percentage of pairs with exact agreement or agreement within one grade will also be of interest from the standpoint of education and quality improvement, but are not likely to be statistically meaningful because of verification bias (lack of histology follow-up on patients with negative cytology.) More complex methods of compensating for verification bias exist but are more applicable in research settings than for routine clinical practice 2 IX
3 Although somewhat non-intuitive, an unusually high PV+ may be a clue to an excessive cytology undercall rate. 8. Discrepancy Evaluation and Performance Criteria: Specified action plan if limits for non-correlation are exceeded a. FP cytology/histology (low PV+) b. FN cytology/histology i. As discussed above, a statistically meaningful FN rate cannot be determined from routine C/H correlation because of verification bias, however when major FN discrepancies are identified they should be investigated and assessed for quality improvement opportunities. Although somewhat non-intuitive, an unusually high PV+ may be a clue to an excessive cytology undercall rate. This can occur if the morphologic threshold for HSIL is too high. For example, if only those cases with the most distinct and striking features of HSIL are interpreted as such and other cases which may fulfill cytomorphologic criteria for HSIL but are less striking are interpreted as less than HSIL, the PV+ of HSIL Paps will be higher than it would be with a lower threshold for a HSIL interpretation. Careful review of rates of HSIL histology following cytologic interpretations of ASC-US, ASC-H, and LSIL might reveal opportunities for improvement in this scenario. The false positive rate will increase with a lower threshold, so laboratories should strive for a reasonable compromise, and most importantly seek to minimize major undercalls. A hypothetical example of a cytology-histology correlation procedure is presented below. Any numbers presented within it are fictitious. Hypothetical Example of a GYN Cytology- Correlation Protocol Inclusion Criteria: Surgical pathology specimens of cervical biopsies, endocervical curetting and biopsies, loop electrosurgical excision (LEEP), conization, and hysterectomies that include the cervix or endocervix will be paired with corresponding Pap tests from the same patient which have been accessioned within 6 months prior to accession of the histology specimen. Time of Correlations (in routine workflow): Correlations of individual case pairs will be performed at the time of sign-out of the surgical pathology specimen. Correlation data will be summarized on a monthly basis. Search Logistics: When one of the specified specimen types is being examined in surgical pathology, the Cytology Correlation function of the Laboratory information System will be utilized to identify prior cytology cases accessioned within 6 months of the current surgical pathology specimen. Correlation Definitions: Cases in which one of the specimens is interpreted as HSIL or worse, and the other is negative/negative for intraepithelial lesion of malignancy (NILM), will be designated as Major Overcalls or Undercalls. Pairs with exact agreement will be designated Agree. Other pairs will be designated as minor overcalls or undercalls. Discrepancies that cannot necessarily be characterized as overcalls or undercalls are designated as variances. A HSIL Pap test with corresponding colposcopic punch biopsy and a LEEP, cone biopsy, or hysterectomy with none revealing SIL is designated FP. A HSIL Pap test with only a corresponding colposcopic punch biopsy with no SIL, but no LEEP or cone biopsy is a major discrepancy, but not a FP at that point in the patient s workup or cytology-histology correlation protocol. X
4 Tabulation of Cytology- Data: Cytology/ pairs will be assessed as shown in the Discrepancy Assessment Grid (Figure 1) below (individual laboratories may make assessments different than those in this hypothetical example). The actual counts a table such as depicted in Figure 2 below. Figure 1. Discrepancy Assessment Grid (Over- and Undercall refer to the cytology interpretation) Pap Diagnosis Biopsy Diagnosis Summary n-dx Benign or Inflam LSIL HSIL Squamous CA Adeno-carcinoma NILM N/A Agree Minor Undercall Major Undercall Major Undercall Major Undercall OTHER EMC45 N/A Agree Minor Variance Major Undercall Major Undercall Minor Undercall ASC-US N/A Minor Variance Agree Minor Undercall Major Undercall Major Undercall LSIL, AGC, AGC-ECX, AGC-EMC N/A Minor Overcall Agree Minor Undercall Minor Undercall Minor Undercall HSIL, ASC-H, AGC-NEO, AGC-ECX/EMC NEO N/A Major Overcall Minor Overcall Agree Minor Undercall Minor Undercall AIS N/A Major Overcall Major Overcall Minor Variance Minor Variance Minor Undercall MALIGNANT N/A Major Overcall Major Overcall Minor Overcall Agree Agree (Numbers represent a hypothetical example.) Figure 2 Figure 3. Cytology- Correlations 50 Cytology NEG LSIL HSIL CA NILM ASC AGC LSIL HSIL CA MinVar MajUnd Minund Agree MinOv MajOver All major discrepancies will be investigated/evaluated utilizing the algorithm published by Tritz. 4 Reviews will be performed by the Technical Supervisor as outlined in the CLIA regulations, section The results from this process can optionally be further summarized by the creation of histograms depicting the number of cytology-histology pairs with exact agreement, minor overcalls and undercalls, and major overcalls and undercalls, etc. (Figure 3) This can be further sub-divided by specific cytologic or histologic interpretations if desired, but pairs in which at least one of the specimens is HSIL or greater are most important clinically. Individual laboratories should determine the most appropriate protocol for themselves. XI
5 Investigation/Evaluation of n-correlating Events: Review Cytology Review Cytology Disagree with Original DX? Disagree with Original DX? Interpretive Error Screening Error Cytology > Cytology < Pap Interpretive Error Review BX Parameters 1. Orientation 2. Size of Bx 3. Site of BX Levels or Reorientation Required? Improvement in Parameters? Cytology > Cytology < Pap Lesion Identified? Cytology > Cytology < Pap Clinical Error Statistical Calculations: 1. Percent of HSIL Pap tests with HSIL histology 2. Percent of HSIL Pap tests with minor discrepancies 3. Percent of HSIL Pap tests with HSIL FP major discrepancies 4. Number of cases with major discrepancy cytology undercalls or FN major discrepancies (Percent FN is not a statistically meaningful number due to a lack of follow-up on most NILM Paps, but the number may be useful in an educational context.) 5. PV+ for HSIL Pap tests Expected Aggregate Correlations, Discrepancy Resolution, and Performance Criteria: All major under-call and major overcall Pap tests will be reviewed. The outcome of this review will be documented in the QA statistics of the individual that was responsible for reviewing the case. 1. FN and major under-call Pap tests will be reviewed by the lead cytotechnologist with the cytotechnologist who initially signed out the case and assessed as a screening or sampling error. 2. FP and major overcall Pap tests will be reviewed by the lead cytotechnologist, cytotechnologist responsible for the initial sign-out of the case, and the pathologist that signed out the case. The case will be assessed as an interpretive error, or if a LEEP or cone has not been performed, as an unresolved major discrepancy. 3. PV+ will be at least 75%. If this criterion is not met, the lead cytotechnologist and cytopathologist will review the summary data and individual cases as necessary to identify a course or courses of correction for the low PV+ rate. Possible sources include individual pathologist(s) with high FP rates, and systematic under-calling of histology specimens, particularly small specimens such as endocervical biopsies, by individual pathologists. Failure to order deeper specimens when appropriate is another possible source of an excessive FP rate. If individual pathologists have PV+ rate >95%, the rate of minor undercalls of histologically proven HSIL+ will be examined and compared to the overall laboratory rate of minor undercalls for proven HSIL+ and this data will be provided to the pathologist. Any corrective action will XII
6 be at the discretion of the laboratory director; corrective action may not be deemed necessary in this scenario. 4. Summary data will be presented to the cytotechnologists and pathologists involved in cytology sign-out on a periodic basis, but at least quarterly. This presentation may be in the form of an in-service presentation or a written report. References 1. Crothers BA, Jones BA, Cahill LA, et al. Quality improvement opportunities in gynecologic cytologic-histologic correlations: findings from the College of American Pathologists Gynecologic Cytopathology Quality Consensus Conference working group 4. Archives of Pathology & Laboratory Medicine. 2013;137(2): Schmidt RL, Factor RE. Understanding sources of bias in diagnostic accuracy studies. Arch Pathol Lab Med. 2013;137(4): Renshaw AA, Granter SR. Appropriate follow-up interval for biopsy confirmation of squamous intraepithelial lesions diagnosed by cervical smear cytology. American Journal of Clinical Pathology. 1997;108(3): Tritz DM, Weeks JA, Spires SE, et al. Etiologies for non-correlating cervical cytologies and biopsies. American Journal of Clinical Pathology. 1995;103(5): Jones BA, vis DA. Cervical biopsy-cytology correlation - A college of American pathologists Q-Probes study of correlations in 348 laboratories. Archives of Pathology & Laboratory Medicine. 1996;120(6): Ince U, Aydin O, Peker O. Clinical importance of low-grade squamous intraepithelial lesion, cannot exclude high-grade squamous intraepithelial lesion (LSIL-H) terminology for cervical smears: 5-year analysis of the positive predictive value of LSIL-H compared with ASC-H, LSIL, and HSIL in the detection of high-grade cervical lesions with a review of the literature. Gynecologic Oncology. 2011;121(1): Rossetti D, Gerli S, Saab JC, Di Renzo GC. Atypical squamous cells of undetermined significance (ASCUS), low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL) and histology. Le Journal Medical Libanais (The Lebanese Medical Journal). 2000;48(3): Castle PE, Cox JT, Schiffman M, Wheeler CM, Solomon D. Factors influencing histologic confirmation of high-grade squamous intraepithelial lesion cytology. Obstetrics and Gynecology. 2008;112(3): Shield PW, Finnimore J, Cummings M, Wright RG. Performance measures for Australian laboratories reporting cervical cytology: a decade of data Pathology. 2010;42(7): XIII
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