Significance of Atypical Glandular Cells of Undetermined Significance on ThinPrep Pap Smears
abstract & commentary
Synopsis: ThinPrep cytology reports of atypical glandular cells of undetermined significance indicate a high risk for significant disease.
Source: Eltabbakh GH, et al. Gynecol Oncol 2000;78:
245-250.
Several recent articles using material from conventional Pap smear preparation techniques have noted that a report of atypical glandular cells of undetermined significance (AGUS) indicates a woman at high risk for significant disease. No previous article has performed a similar retrospective analysis on ThinPrep specimens. The purpose of this study was to do such an analysis.
Eltabbakh and colleagues obtained all smears indicating the presence of AGUS at their institution for a period of slightly less than three years. Eighty-six of 13,134 smears were reported as AGUS. These smears were subdivided into those that favored reactive changes, and those which favored neoplastic changes. Approximately half of the reports were in each category. Of the 42 patients with smears favoring reactive changes, 38 had an evaluation that included colonoscopy. Eventually, five patients were found to have a low-grade squamous intraepithelial lesion (SIL), three had a high-grade lesion, and one had a complex endometrial hyperplasia. Among the 44 patients with smears favoring neoplasia, 38 had colposcopy and most had endometrial biopsies. At the end of the evaluation, three patients were found to have low-grade SIL changes, four high-grade, three adenocarcinoma in situ, one patient had a small cell cervical cancer, and seven had endometrial cancer. Overall, more than 22% of the patients had a significant abnormality identified, and eight had cancer.
Eltabbakh et al discussed their findings and compared them to the previous reports in the literature that used conventional cytology smears. They believe that the ThinPrep technique identifies a similar group of patients when an AGUS report occurs. That is, an AGUS report on a ThinPrep specimen indicates a significant risk for invasive cancer or other serious pathology.
Comment by Kenneth L. Noller, MD
Although all of the studies on AGUS Pap smears have been retrospective in nature, I believe that the data are clear: an AGUS Pap smear report carries a high risk of a significant lesion, including invasive cancer. This article extends our knowledge base somewhat because it indicates that when a ThinPrep specimen is reported as AGUS, there is a significant risk for serious disease, just as with conventional smears.
I probably should stop selecting articles about AGUS smears for OB/GYN Clinical Alert. I have tried to make the point on at least three occasions that an AGUS smear is a very significant report, certainly much more worrisome for invasive cancer than a high-grade SIL lesion, and I should probably stop preaching. The fact remains that when all of the reports in the literature are combined, there is approximately a 10% chance that a woman with an AGUS report has an invasive cancer somewhere.
One note of caution should be raised. I occasionally hear about laboratories that are reporting 2-3% of their smears as AGUS. That is far in excess of any of the published studies where AGUS is reported in only 0.3-0.8% of the samples. If your laboratory is overcalling AGUS, you will certainly have fewer invasive cancers than have been reported in the literature. AGUS is another reason why clinicians should receive regular reports for their cytology laboratory that indicate the percentage of each diagnostic category for the previous several months.
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