Cervix

Premalignant / preinvasive lesions - cytology

ASC-H



Last staff update: 25 January 2023 (update in progress)

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PubMed Search: ASC-H

Joseph Reznicek, M.D.
Bonnie Choy, M.D.
Page views in 2022: 372
Page views in 2023 to date: 95
Cite this page: Reznicek J, Choy B. ASC-H. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/cervixASCH.html. Accessed January 29th, 2023.
Definition / general
  • Atypical squamous cells - cannot exclude high grade squamous intraepithelial lesion (ASC-H) refers to cytologic changes that are suggestive of high grade squamous intraepithelial lesion (HSIL) but insufficient for a definitive interpretation
Essential features
  • Criteria are based on the 2014 Bethesda System for Reporting Cervical Cytology (Nayar: The Bethesda System for Reporting Cervical Cytology, 3rd Edition, 2015)
  • Usually sparse in cellularity
  • Cells resemble immature (basal or parabasal) squamous cells with high N:C ratios
  • Nuclei are ~1.5 - 2.5x larger than normal intermediate nuclei and show nuclear abnormalities
  • Differential diagnosis includes HSIL as well as changes that are not related to human papillomavirus (HPV) infection and neoplasia (e.g., squamous metaplasia, atrophy and intrauterine device [IUD] effect)
CPT coding
  • For screening Pap tests (routine and high risk): smear
    • Manual screening only
      • Technical component: P3000
      • Professional component: P3001
    • FocalPoint (instrument only)
      • Technical component: G0147
      • Professional component: G0141
    • FocalPoint (with manual screening)
      • Technical component: G0148
      • Professional component: G0141
  • For screening Pap tests (routine and high risk): liquid based
    • Manual screening only
      • Technical component: G0123
      • Professional component: G0124
    • ThinPrep imager assisted screening
      • Technical component: G0145
      • Professional component: G0141
    • FocalPoint (instrument only)
      • Technical component: G0144
      • Professional component: G0124
    • FocalPoint (with manual screening)
      • Technical component: G0145
      • Professional component: G0141
  • For diagnostic Pap tests: smear
    • Manual screening only
      • Technical component: 88164
      • Professional component: 88141
    • FocalPoint (instrument only)
      • Technical component: 88147
      • Professional component: 88141
    • FocalPoint (with manual screening)
      • Technical component: 88148
      • Professional component: 88141
  • For diagnostic Pap tests: liquid based
    • Manual screening only
      • Technical component: 88142
      • Professional component: 88141
    • ThinPrep imager assisted screening
      • Technical component: 88175
      • Professional component: 88141
    • FocalPoint (instrument only)
      • Technical component: 88174
      • Professional component: 88141
    • FocalPoint (with manual screening)
      • Technical component: 88175
      • Professional component: 88141
Sites
  • Cervix, vagina, anus
Diagrams / tables

Images hosted on other servers:
Missing Image

Management algorithm for patients < 25 years old

Clinical features
Laboratory
  • HPV testing may be used as part of screening, triage and surveillance (J Am Soc Cytopathol 2020;9:291)
  • Initially endorsed in 2001 as triage test for ASCUS (ASC of undetermined significance) cytologic result
  • Approved for:
    • Cotesting in 2003
    • Postcolposcopic / posttreatment follow up and risk stratification using partial genotype (HPV 16/18) in 2006
    • Primary screening option in 2014
  • 5 FDA approved HPV testing platforms:
    • Qiagen Hybrid Capture
    • Hologic Cervista
    • Hologic Aptima
    • Roche Cobas (FDA approved for primary screening)
    • Becton Dickinson Onclarity (FDA approved for primary screening)
  • Note: HPV result plays no role in the cytologic examination or grading of SIL
Management
  • 2019 American Society of Colposcopy and Cervical Pathology (ASCCP) risk based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors (J Low Genit Tract Dis 2020;24:102)
    • Personalized risk based recommendations based on a patient's risk of cervical intraepithelial neoplasia (CIN) 3+, as determined by a combination of current results and past history (including unknown history)
    • Unlike prior versions, the 2019 guidelines do not provide management algorithms for most screening and triage scenarios
  • For patients < 25 years old with ASC-H cytology, colposcopy is recommended (refer to the management algorithm in Diagrams / tables)
  • For patients ≥ 25 years old with ASC-H cytology:
    • Colposcopy is recommended if HPV status is unknown or negative
    • Colposcopy / treatment is recommended if HPV positive (untyped or genotyped)
  • Use the website or mobile app to calculate risk estimate and determine individualized management recommendation for patients
  • 5 year risks for histologic HSIL and cancer for cytology samples interpreted as ASC-H with high risk HPV testing (N Engl J Med 2013;369:2324):
    • ASC-H with negative HPV: 12%
    • ASC-H with positive HPV: 45%
  • Reference: J Low Genit Tract Dis 2020;24:102
Cytology description
  • Usually sparse cells
  • Common cytologic patterns of ASC-H that are suggestive of HSIL but insufficient for a definitive interpretation (Nayar: The Bethesda System for Reporting Cervical Cytology, 3rd Edition, 2015):
    • Small cells with high N:C ratios (atypical immature metaplastic cells)
      • Seen in rare single cells or in small groups (< 10 cells)
      • Enlarged nuclei (1.5 - 2.5x larger than normal intermediate nuclei)
      • Some nuclear abnormalities; features such as coarse chromatin, focal irregular nuclear contour and hyperchromasia favor an interpretation of HSIL
    • Crowded sheet pattern:
      • Crowded squamous cells with atypical nuclear features, loss of polarity or are difficult to visualize
      • Features such as dense cytoplasm, polygonal shape of the cell and sheets with sharp linear edges favor squamous over glandular differentiation (Hum Pathol 1999;30:816)
Cytology images

Contributed by Bonnie Choy, M.D.

High N:C ratio

Irregular nuclear membranes and hyperchromasia

HSIL

Squamous metaplasia

Atrophy with inflammation

Endometrial cells



Images hosted on other servers:

WHO digital atlas

Sample pathology report
  • Statement of adequacy:
    • Satisfactory for evaluation
    • Transformation zone component present
  • Final interpretation:
    • Epithelial cell abnormality, squamous cell
    • Atypical squamous cells - cannot exclude a high grade squamous intraepithelial lesion (ASC-H)
Differential diagnosis
  • HSIL:
    • Approximately the size of parabasal cells
    • Nuclear atypia, including nuclear enlargement, irregular nuclear contours with frequent prominent indentations / grooves, generally hyperchromatic, lack of nucleoli
    • High N:C ratio
  • Squamous metaplasia:
    • Less nuclear enlargement and lower N:C ratio
    • Minimal to mild nuclear membrane abnormalities
    • If reactive, may have nucleoli
  • Atrophy:
    • Variable N:C ratio
    • Smooth nuclear contours / membranes
    • Smudgy or degenerated nuclear chromatin
    • No mitoses
    • Blood and inflammation may be present but no tumor diathesis
  • Isolated endocervical cells:
    • Presence of small nucleoli
    • Finely granular and evenly distributed chromatin
    • Smooth nuclear contours
    • Granular or finely vacuolated cytoplasm, occasionally with some elongation
    • Exfoliated cells may have rounded up appearance and high N:C ratio
    • Retain columnar cytoplasmic configuration with eccentrically placed nuclei
  • Exfoliated endometrial cells:
    • Small cells with dark nuclei and scant cytoplasm
    • Small nucleoli may be seen
    • Apoptotic bodies may been present within shedding endometrial groups
  • IUD effect:
    • May present as isolated cells with high N:C ratio
    • Degenerative nuclei with wrinkled chromatin
    • Usually more regular nuclear membranes
    • Presence of nucleoli
  • Histiocytes:
    • Small to medium sized, oval kidney bean nuclei
    • Sometimes prominent longitudinal groove
    • Finely textured, normochromatic
    • Abundant foamy vacuolated cytoplasm
Board review style question #1

The cervical cytology specimen shown above is from a 35 year old woman. What is the most likely interpretation?

  1. Atypical glandular cells, NOS
  2. Atypical squamous cells - cannot exclude HSIL (ASC-H)
  3. Atypical squamous cells - undetermined significance (ASCUS)
  4. Low grade squamous intraepithelial lesion (LSIL)
Board review style answer #1
B. Atypical squamous cells - cannot exclude HSIL (ASC-H)

Comment Here

Reference: ASC-H
Board review style question #2
A cervical cytology specimen shows very rare cells with nuclear atypia, irregular nuclear contours and high N:C ratios, concerning but not definitive for the diagnosis of high grade squamous intraepithelial lesion. What is the best interpretation?

  1. Atypical squamous cells - cannot exclude HSIL (ASC-H)
  2. Atypical squamous cells - undetermined significance (ASCUS)
  3. High grade squamous intraepithelial lesion (HSIL)
  4. Low grade squamous intraepithelial lesion (LSIL)
Board review style answer #2
A. Atypical squamous cells - cannot exclude HSIL (ASC-H)

Comment Here

Reference: ASC-H
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