Cervical cytology with a diagnosis of at least low-grade squamous intraepithelial lesion cannot exclude high-grade squamous intraepithelial lesion (LSIL-H) what does this mean in HIV positive women?: a cytologic-histological correlation

Abstract

Introduction: The Bethesda System for reporting cervical cytology divides squamous intraepithelial lesions into low grade and high grade. Diagnostic dilemmas occur when the cytomorphology is intermediate between LSIL and HSIL [At least LSIL – cannot exclude HSIL/LSIL-H]. HIV-infected women have high rates of HPV-related disease. The aim of this study was to determine the histologic outcome and best management strategy for HIV-positive women with a cytologic diagnosis of LSIL-H in a resource constrained setting. Methods: A retrospective analysis was performed whereby histologic follow up was sought on 3678 abnormal Pap smears over a two-year in HIV-positive women at a single urban institutions in South Africa. Results: Of 3678 abnormal smears LSIL-H comprised 191 [5.2%], ASCH 217 [5.9%], ASCUS 602 [16.4%], LSIL 2147 [58.4%], HSIL 497 [13.5%] and 23 [0.6%] squamous cell carcinoma. Histologic results were available in 70.3%. The most common histologic outcome for LSIL-H was LSIL in 61.8% while 31.8% showed HSIL. This is similar to ASCH with a histologic diagnosis of LSIL of 57.8% and HSIL of 26.7%. This histologic follow up of women with a cytologic diagnosis of LSIL was 75% and 13.1% HSIL while that for HSIL was 31.6% LSIL and 63.2% HSIL. The most frequent CD4 count in women with LSIL-H cytology was 1000, ASCH,LSIL and HSIL was 800-900, 700-800 and less than 200 respectively The majority of LSIL-H smears were in women aged 20-29 while that for ASCH, LSIL and HSIL was 60-69, 30-39 and 20-29 respectively. Discussion/conclusion: The majority of HIV-positive women with a cytologic diagnosis of LSIL-H will have histologic follow up showing LSIL with approximately one quarter showing HSIL. This is similar to those with ASCH. Thus, smears showing cytomorphology intermediate between LSIL and HSIL may be reported as ASCH and the appropriate management, even in resource constrained setting, would be colposcopy and directed biopsy