Original Article

Cytologic Patterns of Cervical Adenocarcinomas With

Emphasis on Factors Associated With Underdiagnosis
Rachel D. Conrad, MD1 ; Angela H. Liu, MD2; Nicolas Wentzensen, MD, PhD2 ; Roy R. Zhang, MD1;
S. Terence Dunn , PhD ; Sophia S. Wang, PhD ; Mark Schiffman, MD, PhD ; Michael A. Gold, MD4;
1 3 2

Joan L. Walker, MD4; and Rosemary E. Zuna, MD1

BACKGROUND: New cervical cancers continue to be diagnosed despite the success of Papanicolaou (Pap) tests. In an
effort to identify pitfalls that limit the diagnosis of adenocarcinoma, the authors reviewed the cytologic characteristics
of endocervical adenocarcinomas in their patient population. METHODS: Liquid-based cytology slides from 45 women
who had concurrent, histologically confirmed cervical adenocarcinomas were reviewed retrospectively and semiquanti-
tatively for 25 key cytologic traits. The original sign-out diagnosis, available clinical findings, and high-risk human papil-
lomavirus (HR HPV) results also were noted. RESULTS: Abundant tumor cellularity, nuclear size from 3 to 6 times normal,
abundant 3-dimensional tumor cell groups, round cell shape, and cytoplasmic neutrophils characterized the 23 cases
that were identified correctly as adenocarcinomas. Key reasons for undercalls included low tumor cellularity and low-
grade columnar morphology; these also tended to correlate with low-grade or unusual adenocarcinoma variants on
histology. Overall, 73% of adenocarcinomas had a concurrent positive HR HPV test. CONCLUSIONS: Most endocervical
adenocarcinomas can be diagnosed accurately in cases with classical features, but some cases continue to be problem-
atic when evaluated based on cytologic features alone. Reflex HPV testing may help increase Pap test sensitivity for
challenging cases that have atypical glandular cells of undetermined significance. Occasional cases with negative HR
HPV test results remain of concern. Cancer Cytopathol 2018;126:950-958. © 2018 The Authors. Cancer Cytopathology
published by Wiley Periodicals, Inc. on behalf of American Cancer Society.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial
and no modifications or adaptations are made.

KEYWORDS: adenocarcinoma, cancer screening, cytodiagnosis, Papanicolaou test, uterine cervical neoplasia.

INTRODUCTION
Despite the success of Papanicolaou (Pap) smear screening and the promise of human papillomavirus (HPV)
vaccination, approximately 12,990 new cervical cancers were identified in the United States in 2016.1 In an
effort to improve our ability to recognize malignant cases in routine screening, we previously reported our
experience with Pap test interpretation in a large population of women who were referred for workup of ab-
normal cervical cytology, including women with cervical carcinoma,2 and observed an increase in suboptimal
interpretations (ie, qualified adequacy and unsatisfactory) among women who had cancers compared with
those who had less significant diagnoses. This was particularly true for women who had squamous cancers.
We also observed that Pap tests from women who had adenocarcinomas were less likely to be recognized as

Corresponding author: Rosemary E. Zuna, MD, Department of Pathology, University of Oklahoma Health Sciences Center, 940 Stanton L. Young
Boulevard, Room 451, Oklahoma City, OK 73104; rosemary-zuna@ouhsc.edu
1
Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; 2Division of Cancer Epidemiology and
Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland; 3Cancer Etiology, Beckman Institute, City of Hope, Duarte,
California; 4Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma
City, Oklahoma
Received: June 13, 2018; Revised: July 12, 2018; Accepted: July 30, 2018, Published online October 23, 2018 in Wiley Online Library (wileyonlinelibrary.com)
DOI: 10.1002/cncy.22055, wileyonlinelibrary.com

950 Cancer Cytopathology  November 2018

 Patterns in Cervical Adenocarcinomas/Conrad et al

malignant compared with those from women who had using the Linear Array HPV Genotyping Test (Roche
squamous cancers, although most were recognized with Molecular Diagnostics, Pleasanton, CA), as previously
some degree of abnormality. described.8 HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52,
Subsequently, we compared the cellular patterns of 56, 58, 59, 66, and 68 were considered to be carcinogenic
squamous cancers and adenocarcinomas3 and observed (high-risk [HR] HPV types). Adenocarcinoma cases that
that squamous cancers had more pronounced tumor di- were interpreted as primary from the endometrium at
hysterectomy were excluded from this study.
athesis, which, with ThinPrep Pap tests (Hologic Inc,
The 45 adenocarcinoma cases described here were
Marlborough, MA), was accompanied by differences in
extracted from our previous descriptions of this popu-
tumor cellularity. Specifically, the prominent tumor di-
lation.2,3 The de-identified ThinPrep slides were retro-
athesis associated with squamous cancers was accompa-
spectively reviewed for key cytologic elements (see below)
nied by tumor cells and fewer cells overall. Conversely,
without knowledge of the original cytologic interpreta-
adenocarcinomas had less diathesis and had a larger pop-
tion. For each case, each element was assessed semiquan-
ulation of normal-appearing endocervical cells.
titatively and scored as 0 (little or none), 1+ (some), 2+
Because the rates of cervical adenocarcinoma diag-
(many/much), or 3+ (abundant).
noses appear to be increasing relative to squamous cancer
We conducted chi-square tests to evaluate distri-
diagnoses,4,5 these findings led us to focus on the cyto-
butions of categorical variables. All statistical tests were
logic characteristics of adenocarcinomas in our patient
2-sided and considered to be significant at P < .05.
population in an effort to identify features that may be
associated with underdiagnosis of this lesion.
RESULTS
MATERIALS AND METHODS The key clinical characteristics of the patients with ad-
enocarcinoma who were included in this study are pro-
The ThinPrep Pap tests originally were collected from 45
vided in Table 1. It is noteworthy that 73.3% the patients
women who had concurrent histologic diagnoses of cer-
were positive for HR HPV genotypes. The cytologic
vical adenocarcinoma as part of the Study to Understand
features analyzed retrospectively in our review of these
Cervical Cancer Early Endpoints and Determinants
slides are listed in Table 2.
(SUCCEED)6‒8 and the National Cancer Institute-
University of Oklahoma Health Sciences Center Biopsy The relative distribution of the various cellular
Studies.9 Each woman provided informed consent, and characteristics observed in these cases of cervical adeno-
the studies were approved by the institutional review carcinoma is provided in Table 2. In aggregate, the char-
boards of the University of Oklahoma Health Sciences acteristics most frequently recognized in this population
Center and the National Cancer Institute. The 3015 of cervical adenocarcinomas include: abundant cells, in-
study participants were women aged 18 to 85 years who cluding tumor cells; abundant 3-dimensional tumor cell
were referred for follow-up of abnormal Pap tests or of a groups; nuclear size 3 to 6 times normal; tumor diathe-
diagnosis of cancer between 2002 and 2010. Women who sis; and small, definite nucleoli. Conversely, psammoma
had undergone previous surgery for cervical neoplasia, bodies and histiocytes rarely were noted. The remaining
those with human immunodeficiency virus infections, traits were variably present in this group of cases.
or those who were pregnant were excluded. At the time Although all cases in this study were histologically con-
of study entry, participants provided informed consent
firmed adenocarcinomas coincident with the Pap test, there
and underwent ThinPrep Pap testing and colposcopy,
were various interpretations at the time of original cytology
with further treatment according to routine patient care
guidelines. The ThinPrep Pap tests were originally evalu- sign-out. These included 23 cases correctly diagnosed as
ated in a routine fashion by staff cytotechnologists and adenocarcinoma (CA); 15 cases as high-grade squamous in-
study cytopathologists at the University of Oklahoma traepithelial lesion (HSIL), atypical glandular cells (AGCs)
Medical Center laboratories according to the 2001 or adenocarcinoma in situ (AIS) (high grade), and 6 were
Bethesda guidelines.10 An aliquot of each cytologic sam- diagnosed as low-grade squamous intraepithelial lesion
ple underwent HPV genotyping for 37 HPV genotypes (LSIL), atypical squamous cells (ASC), ASC cannot rule

Cancer Cytopathology  November 2018 951

Original Article

TABLE 1. Key Clinicopathologic Features of 45 Cases Correctly Identified as

Patients With Cervical Adenocarcinoma Adenocarcinoma
Trait No. of Patients (%) When comparing findings from the 23 cases that were
Age, y correctly identified as adenocarcinoma at the time of
≤30 6 (13.3)
original sign-out compared with findings from lesser
31-40 14 (31.1)
1-50 12 (26.7) diagnoses, most cases (19 of 23 cases; 82.6%) that were
51-60 9 (20.0) interpreted correctly as cancer had many or abundant
≥61 4 (8.9)
Stage
tumor cells compared with cases that had lesser diagno-
IA 2 (4.4) ses (P = .02).
IB1 25 (55.6) Similarly, most cases that were interpreted correctly
IB2 5 (11.1)
II 7 (15.5) as adenocarcinoma (17 of 23 cases; 73.9%) had many or
III 1 (2.2) abundant tumor cells with a round/oval appearance, pos-
IV 2 (4.4)
Not done 3 (6.7) sibly indicating a higher grade compared with 6 of 22
FIGO grade cases (27.3%) that had lesser diagnoses (P = .002).
1 10 (22.2)
2 14 (31.1) Among the 23 cases that were identified correctly
3 15 (33.3) as adenocarcinoma at the time of original sign-out, com-
Not done 6 (13.3)
HPV status pared with those of lesser diagnoses, the dominant, key
High risk 33 (73.3) cytologic features included overall greater tumor cellular-
Low risk 1 (2.2)
Negative 10 (22.2)
ity (19 of 23 cases; 82.6%); cohesive, 3-dimensional cell
Not done 1 (2.2) groups (19 of 23 cases; 73.9%); and round-oval tumor cell
Original impression
Adenocarcinoma 24 (53.3)
shape (17 of 23 cases; 73.9%) (Table 3). In contrast, the
Squamous carcinoma 0 (0.0) cases that were interpreted correctly as cancer had fewer
AGCs 11 (24.4)
HSIL 4 (8.9)
normal-appearing endocervical cells and fewer tumor
ASC-H 1 (2.2) cells with a columnar configuration (Table 3). Overall,
ASCUS 2 (4.4)
19 of these cases (82.6%) harbored HR HPV genotypes.
Negative 2 (4.4)
Unsatisfactory 1 (2.2)
Adequacy Cases Interpreted as Less Than HSIL
Adequate 44 (97.8)
Unsatisfactory 1 (2.2) Six cases were interpreted originally as less than high
Limiting factors grade and, for the purposes of the current study, are
Bloody 4 (8.9)
Hypocellular unsatisfactory 1 (2.2)
considered undercalls. The results from a comparison
No T-zone 6 (13.3) between these 6 cases and cases that were diagnosed as
Inflammation 1 (2.2) cancer are provided in Table 3. The features that most
None 34 (75.5)
clearly distinguished the cases interpreted as adenocar-
Abbreviations: AGCs, atypical glandular cells; ASC-H, atypical squamous
cells, cannot exclude a high-grade squamous intraepithelial lesion; cinoma from these 6 cases were increased tumor cellu-
ASC-US, atypical squamous cells of undetermined significance; FIGO, larity; increased presence of cohesive, 3-dimensional cell
International Federation of Gynecology and Obstetrics; HPV, human papil-
lomavirus; HSIL, high-grade squamous intraepithelial lesion.
groups; round-oval tumor cell shape; and cell groups
with frayed edges. The cases with lesser diagnoses were
noteworthy for having fewer tumor cells and for having
out HSIL (ASC-H), or negative for intraepithelial lesion or columnar-shaped tumor cells.
malignancy (less than high grade). The latter cases were in- An additional case that was interpreted as unsatis-
terpreted as undercalls for the purposes of the current study. factory for cytologic diagnosis because of insufficient cel-
One case was unsatisfactory because of hypocellularity. lularity was not included in the above comparison. Four
In an effort to identify factors that facilitated or of these 7 cases (57%) were positive for HR HPV DNA,
hampered the identification of adenocarcinoma, we com- although 2 were unusual histologic types that did not
pared the various cytologic characteristics in cases with appear to be associated with HPV (Table 4).
the various diagnostic interpretations. The key findings We re-reviewed the ThinPrep slides from these 7
from these comparisons are provided in Table 3. cases after the analysis in an effort to understand the

952 Cancer Cytopathology  November 2018

 Patterns in Cervical Adenocarcinomas/Conrad et al

TABLE 2. Relative Distribution of Cytologic Features in 45 Cases of Cervical Adenocarcinoma

Score (%)

Trait 0: Few/None 1+: Some 2+: Many 3+: Abundant

Overall tumor cells 0 (0.0) 15 (33.3) 12 (26.7) 18 (40.0)
Normal endocervical cells 14 (31.1) 21 (46.7) 10 (22.2) 0 (0.0)
Background
Blood 14 (31.1) 15 (35.6) 12 (26.7) 3 (6.7)
RBCs 13 (28.9) 14 (31.1) 15 (33.3) 3 (6.7)
Diathesis 5 (11.1) 13 (28.9) 9 (20.0) 18 (40.0)
Inflammation 4 (8.9) 14 (31.1) 19 (42.2) 8 (17.8)
Histiocytes 31 (68.9) 12 (26.7) 2 (4.4) 0 (0.0)
Psammoma bodies 45 (100.0) 0 (0.0) 0 (0.0) 0 (0.0)
Tumor cell pattern
3-D groups 2 (4.4) 11 (24.4) 19 (42.2) 13 (28.9)
Single atypical cells 10 (22.2) 26 (57.8) 9 (20.0) 0 (0.0)
Tumor cell morphology
Columnar 16 (35.6) 11 (24.4) 12 (26.7) 6 (13.3)
Round/oval 2 (22.2) 20 (44.4) 14 (31.1) 9 (20.0)
Frayed edges 10 (22.2) 18 (40.0) 13 (28.9) 4 (8.9)
Loss of polarity 3 (6.7) 18 (40.0) 17 (37.8) 7 (15.6)
Abundant cytoplasm 7 (15.6) 21 (46.7) 14 (31.1) 3 (6.7)
Cytoplasmic mucin 34 (75.6) 9 (20.0) 2 (4.4) 0 (0.0)
Polys in cytoplasm 25 (55.6) 15 (33.3) 4 (8.9) 1 (2.2)
Nuclear size
Nearly normal 19 (42.2) 19 (42.2) 5 (11.1) 2 (4.4)
4-6 Times normal 2 (4.4) 9 (20.0) 22 (48.9) 12 (26.7)
>6 Times normal 9 (20.0) 21 (46.7) 9 (20.0) 6 (13.3)
Mitotic figures 23 (51.1) 16 (35.6) 6 (13.3) 0 (0.0)
Nucleoli
Large single 15 (33.3) 14 (31.1) 11 (24.4) 5 (11.1)
Multiple 22 (48.9) 18 (40.0) 5 (11.1) 0 (0.0)
Small, definite 4 (8.9) 13 (28.9) 16 (35.6) 12 (26.7)
Inconspicuous 24 (53.3) 17 (37.8) 4 (8.9) 0 (0.0)
Abbreviations: 3D, 3-dimensional; RBCs, red blood cells.

reasons for the undercalls, and the summaries are pro- In some cases, small groups of tightly cohesive
vided in Table 4 along with representative images in tumor cells were observed (Fig. 1B), but these were
Figure 1. Overall, there were 2 major reasons for the un- smaller than the large groups typically observed in ade-
dercalls: 1) few tumor cells and 2) low tumor grade with nocarcinoma. In addition, it was difficult to evaluate the
bland-appearing tumor cells. Both problems were present nuclear features of the cells in these groups because of
in some of these cases. crowding. Only case 6 (Fig. 1G) had a rare group that
The pattern of hypocellularity in malignant could have raised concern for possible adenocarcinoma;
ThinPrep Pap tests with dense rings of diathesis de- however, this was only recognized on re-review.
marcating an empty central portion has been well de- The second problem relates primarily to well differ-
scribed.11,12 We highlighted this as a particular problem entiated tumors of usual endocervical type in which the
for squamous cell cancer cases.3 We observed that this cytologic characteristics of the tumor cells overlap with
was a lesser problem for ThinPrep slides from adenocar- benign, reactive changes. Recognition of these cases also
cinoma cases; however, 1 case in this group of undercalls was hampered by various degrees of acute inflammation.
(a clear cell carcinoma) had the same pattern of hypocel- In addition, nuclear criteria were bland, with minimally
lularity (Fig. 1A). In addition, other cases exhibited an enlarged nuclei; a bland, uniform chromatin pattern;
unremarkable pattern of overall cellularity but had few and small nucleoli. Typically, the undercalled cases in
recognizable tumor cells, suggesting sampling issues. In our population had a combination of few tumor cells
these cases, the number and characteristics of the tumor and small tumor cell groups as well as bland cytologic
cells were insufficient to trigger the recognition of a sig- features. These cases also had subtle patterns of amor-
nificant lesion. phous debris and ghost erythrocytes that helped obscure

Cancer Cytopathology  November 2018 953

Original Article

TABLE 3. Key Cytologic Traits Differentiating Adenocarcinoma Interpretations From Cases With Lesser
Diagnoses

Carcinoma, N = 23 Less Than Carcinoma, N = 15 Less Than High Grade, N = 6

Trait No. (%) a No. (%) a P No. (%) a P

Overall tumor cellularity 19 (82.6) 8 (53.3) .052 3 (50.0) .04
Cohesive 3D cell groups 19 (82.6) 10 (66.6) .26 3 (50.0) .04
Round/oval cell shape 17 (73.9) 4 (26.6) .01 1 (16.7) .005
Groups with frayed edges 11 (47.8) 6 (40.0) .64 0 (0.0) .02
Columnar shape 5 (21.7) 8 (53.3) .04 4 (66.7) .01
Normal appearing endocervical cells 2 (8.7) 6 (40.0) .02 2 (33.3) .18
Abbreviation: 3D, 3-dimensional.
a
Values indicate the sum of the number of cases with the indicated trait showing “many” and “abundant” cells

the cellular detail in the dense cell groups. Although this criteria for adenocarcinoma 20 were recognized in most of
latter finding can raise the index of suspicion and cause the cases in this study, we reluctantly conclude that some
the cytologist to search for more diagnostic criteria in cases continue to be problematic upon reevaluation using
the slide, this pattern can be observed in benign cases cytologic features alone.
and cannot be relied upon alone to identify a high-risk There have been various reports describing criteria
glandular lesion. Overall, the cytologic characteristics of for distinguishing benign glandular mimics, including
these undercalled cases were insufficient to warrant a di- reactive inflammatory changes, microcystic glandular
agnosis of adenocarcinoma even on re-review. hyperplasia, and ciliated metaplasia from glandular neo-
plasia.14,17‒19 Lee and colleagues14 described a case series
DISCUSSION in which glandular lesions were both overcalled and un-
dercalled based on cytologic criteria alone, and a subse-
Previous studies analyzing atypical glandular cells in Pap
tests, including liquid-based Pap tests, have reported dif- quent report17 documented a high level of interobserver
ficulties in accurate interpretation, both in detection and disagreement for cases interpreted as AGC. Schoolland et
in accurate categorization. These difficulties involved al21 reported significant sampling and diagnostic errors
discrimination of glandular lesions from squamous le- in 36 smears from 24 women with cervical adenocarci-
sions13 and from benign glandular mimics.14‒19 Our pre- noma. Ruba et al22 described sampling and interpretive
vious studies with cytologic diagnosis of cervical cancers errors for the cytologic diagnosis of AIS and concluded
have reported greater difficulty in recognizing adenocar- that diagnostic errors were associated with the presence
cinomas compared with squamous cancers.2,3 of only a few, poorly preserved, abnormal cells and an
The current study was undertaken in an effort to overly conservative approach to the assessment of abnor-
increase our ability to recognize the salient features of mal glandular groups/cells. In comparing the screening
cervical adenocarcinoma and its precursors on cytologic histories of women with cervical cancer, Pak and col-
screening and to identify possible reasons for undercalls. leagues23 observed that women who had adenocarci-
The key cytologic criteria that allowed recognition of ad- noma had been screened more regularly and were more
enocarcinoma in this study reflect published criteria, in- likely to have negative Pap test results than those who
cluding abundant, large, atypical tumor cell groups with had squamous cancers. Thus, although adenocarcinoma
atypical single cells. Notably, tumor diathesis was gener- and AIS can be diagnosed accurately in a large number
ally present but, as we have previously reported, to a lesser of cases with classical features of malignancy, a variable
extent than for squamous cancers.2 When we reevaluated number of cases can be missed because of sampling and
the cases that we considered to be undercalled, the dif- interpretative errors when evaluated by cytology alone.
ficulties generally related to hypocellularity (particularly Because of the variation in histologic cell types
of tumor cells, even if overall cellularity was satisfactory) and the variety of cytologic patterns of cervical adeno-
and well differentiated adenocarcinomas with columnar carcinoma, it occurred to us that sensitivity could be
cells and minimal atypia. Although the current cytologic improved with an adjunct test like HPV, which is more

954 Cancer Cytopathology  November 2018

 TABLE 4. Characteristics of Cases With Undercalled ThinPrep Papanicolaou Tests

No. Patient Pap Diagnosis Histology Grade Size, cm HPV Type(s) Comment
1 Age 36 y, WF, G0 Unsatisfactory Clear cell adenocarci- NA 1.0 Negative Excess blood and very low cellularity; several
noma, stage IB1 large cell groups present (>30 cells) in bloody
rim were all monomorphic (a clue that this was
not a normal cell population)
2 Age 35 y, WF, G3 NILM Cervical adenocarcinoma, 1 1.0 16 and18 Very scant tumor cells; small lesion; tightly
usual type, stage IB1 cohesive cell groups with overlapping nuclei
3 Age 57 y, WF NILM Cervical adenocarcinoma, 2 1.4 16 The most prominent part of this case was the
usual type, stage IB1 light diathesis in the background; rare, large
groups of glandular cells with rim of ghost RBCs
4 Age 67 y, WF ASC with obscuring Poorly differentiated 3 3.0 Negative Only rare epithelial cells present with a rim of
inflammation carcinoma, concerning mostly neutrophils; the epithelial cells do not
for carcinosarcoma exhibit definite malignant features; some
laboratories could call unsatisfactory
5 Age 54 y ASC-US Cervical adenocarcinoma, 1 1.0 16 Sheets of atrophic squamous cells are
usual type, stage IB1 distractors; some large, 3-D groups of small
glandular cells with tight, overlapping nuclei;

Cancer Cytopathology  November 2018

little atypia; rare apoptotic cells present
6 Age 35 y ASC-H Cervical adenocarcinoma, 1 1.2 18 Many of the tumor cells have bland chromatin
usual type, stage IB1 and multiple small nucleoli; oval cytoplasm;
some with tails; although many tumor cells are
enlarged, others overlap with normal size nuclei;
prominent neutrophils in background; several
cell groups have definite mucin globules with
signet ring features; diathesis inconspicuous in
this case, although a few aggregates of ghost
RBCs are present
7 Age 35 y ASC-H Mixed cervical adenocar- 1 Not done 16 At low power, the background looks clean;
cinoma, usual type and however, at higher power, aggregates of ghost
small-cell neuroendo- RBCs can be observed; very rare, small, highly
crine, stage IVB cohesive cell groups are present that easily can
be overlooked; small coagulum of fibrin, PMNs
and occasional small epithelial cells are unusual
Abbreviations: 3D, 3-dimensional; ASC-H, atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion; ASC-US, atypical squamous cells of undetermined significance; G, gravidity; HPV,
human papillomavirus; NA, not applicable; NILM, negative for intraepithelial lesion or malignancy; Pap, Papanicolaou test; PMNs, polymorphonuclear leukocytes; RBCs, red blood cells; WF, white female.

955
Patterns in Cervical Adenocarcinomas/Conrad et al
Original Article

objective. Recent, large, international studies of cervical A pooled analysis of HPV screening trials suggested that
adenocarcinomas reported that approximately 62%24 of HPV screening, versus cytology screening, can lead to
cervical adenocarcinomas harbor HR HPV DNA, in- a stronger relative reduction of adenocarcinomas com-
cluding 71.8%25 of adenocarcinomas of the usual type. pared with squamous cell cancers.26

Figure 1. These are images from cases that had undercalled Papanicolaou tests (case numbers correspond to Table 4). (A) Case
1: Dense, bloody diathesis obscures a large monomorphic cell group in a hypocellular specimen (original magnification ×60). (B)
Case 2: A tightly cohesive group has overlapping nuclei such that nuclear detail is obscured (original magnification ×40). (C,D)
Case 3: Light diathesis is observed with a rare, large, highly cohesive group of glandular cells that have obscured cellular detail
(original magnification ×20 in C, ×40 in D). (E) Case 4: A rare, small epithelial group has neutrophils in a sparsely cellular sample
(original magnification ×40). (F) Case 5: This image shows a rare, large, 3-dimensional group of crowded but minimally atypical
glandular cells with abundant atrophic squamous sheets (original magnification ×40). (G) Case 6: This pattern with enlarged
nuclei and prominent intracytoplasmic mucin was rare in this sample (original magnification ×60). (H) Case 7: Very scant, small,
cohesive cell groups with a clean background are easy to overlook (original magnification ×40).

956 Cancer Cytopathology  November 2018

 Patterns in Cervical Adenocarcinomas/Conrad et al

When the Bethesda 2001 guidelines introduced may not be detected by HR HPV testing. Indeed, 2 cases
HPV testing into cervical cancer screening as a reflex test, on our problematic case list were cancers of an unusual type
it was aimed at efficiently triaging the large number of that were not associated with HR HPV. This can be caused
ASC cases, but it did not include AGC.27 Current guide- by false-negative HPV DNA tests or the presence of HPV-
lines for the follow-up of AGC call for referral to colpos- negative cancers, including special types, such as clear cell or
copy.28 Consequently, some cytologists may use a higher serous cancers. The detection of these cases will continue to
threshold for AGC compared with that for ASC. Earlier rely on astute cytologic evaluation and clinical parameters.
studies have indicated that AGC is associated with a high In summary, although most cervical adenocarcino-
rate of high-grade lesions, particularly HSIL.14 This may mas can be detected by using classic cytologic criteria,
be influenced in part by conservative interpretation of recognition of some cases is hampered by subtle tumor
AGC to prevent unnecessary colposcopy visits and loop diathesis, few tumor cells, and very bland cytologic fea-
electrosurgical excision procedures. tures in well differentiated tumors. We propose that
The results of our current study cause us to question reflex HR HPV testing for AGC, as for ASC, can help
whether the use of HPV testing for AGC should be recon- to increase sensitivity for low-grade adenocarcinomas
sidered. Because HPV testing is widely used for ASC re- of the usual type, including precursor lesions, although
flex and as a cotest for women over age 30 years, reflex HR guidelines should remain for the identification of HPV-
HPV testing for AGC could increase our sensitivity for negative cervical cancers and endometrial cancers.
cervical glandular neoplasia with minimal cost and incon-
venience. Four European countries have included AGC as FUNDING SUPPORT
Funding for the Study to Understand Cervical Cancer Early Endpoints
an indication for triage to HPV testing in some European
and Determinants (SUCCEED) was provided through the Intramural
countries.29 On the basis of the earlier literature15,17,18 and
Research Program of the National Institutes of Health, National Cancer
our own experience, this high threshold for AGC may re- Institute, Division of Cancer Epidemiology and Genetics (contract
sult in the underinterpretation of precancer and small, N02-CP-31,102; Joan L. Walker, principal investigator).
well differentiated lesions as reactive changes in an effort
to avoid unnecessary colposcopies for reactive lesions. CONFLICT OF INTEREST DISCLOSURES
Reflex HPV testing for AGC could be added to the Nicolas Wentzensen is employed by the National Cancer Institute and
has received cervical cancer screening assays in-kind or at reduced cost
follow-up algorithm as an initial step to distinguish HR
from Becton-Dickinson and Roche outside the submitted work. Mark
HPV-associated cervical lesions from benign mimics and
Shiffman has received equipment and reagents as well as cervical human
endometrial lesions. Thus, the threshold for AGC could be papillomavirus testing, cytology, and visual images for independent stud-
lowered as well if the concern for unnecessary colposcopies ies from Roche, Becton-Dickinson, Qiagen, and MobileODT. The re-
is removed. Additional safeguards can continue to be in- maining authors made no disclosures.
cluded for HPV-negative cases to detect endometrial lesions.
Previous authors have reported the utility of HPV testing in AUTHOR CONTRIBUTIONS
Rachel D. Conrad: Investigation and writing–review and editing.
AGC cases with favorable results.16,30,31 Ronnett et al16 re-
Angela H. Liu: Formal analysis and writing–review and editing. Nicolas
ported that the combination of cytology interpretation and
Wentzensen: Conceptualization, formal analysis, and writing–review
HPV testing was associated with a high rate of detection of and editing. Roy R. Zhang: Conceptualization, and writing–review
significant glandular lesions. In our sample, 33 of 45 cyto- and editing. S. Terence Dunn: Writing–review and editing. Sophia
logic samples (73%) of cervical adenocarcinomas were pos- S. Wang: Conceptualization and writing–review and editing. Mark
itive for HR HPV. Thus, the detection of adenocarcinoma Shiffman: Conceptualization and writing–review and editing. Michael
A. Gold: Conceptualization and writing–review and editing. Joan L.
and precursors in a screening test can reasonably be expected
Walker: Conceptualization and writing–review and editing. Rosemary
to be improved by HPV testing of AGC Pap tests. Kinney
E. Zuna: Conceptualization, investigation, writing–original draft, and
and colleagues32 have reported adenocarcinoma cases in writing–review and editing.
their cotesting experience that were detected by a positive
HPV test when cytology was negative. In addition, the ac- REFERENCES
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Cancer. Bethesda, MD: National Cancer Institute, National
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Cancer Cytopathology  November 2018 957

Original Article

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