CHAPTER 13 
Cervical Squamous Neoplasia
Christopher P. Crum, Emily E. Meserve, and William A. Peters III
Chapter Outline
INTRODUCTION
Definition
Identifying Patients at Risk for Cervical Neoplasia
The Squamocolumnar Junction
Human Papillomaviruses
Non-Viral Factors
Human Papillomavirus Testing
Current Screening Algorithms
CYTOLOGY
NONDIAGNOSTIC SQUAMOUS ATYPIA (ATYPICAL SQUAMOUS
CELLS OF UNDETERMINED SIGNIFICANCE)
Introduction
Cytologic Alterations That Are Best Left Out of the ASCUS Category
Cytologic Criteria for the Diagnosis of ASCUS
Cytologic Criteria for Squamous Intraepithelial Lesions
Low-Grade Squamous Intraepithelial Lesions
High-Grade Squamous Intraepithelial Lesions
Differential Diagnosis of Low-Grade and High-Grade Squamous Intraepithelial Lesion
Introduction
Definition
Cervical squamous neoplasia is defined as all squamous cell
alterations that occur in or near the cervical transformation
zone and are causally related to human papillomavirus
(HPV) infections. The terms cervical intraepithelial neoplasia
(CIN), dysplasia, and squamous intraepithelial lesion (SIL)
apply to this group of lesions as well. In this chapter, the
terms CIN1, flat condyloma, and exophytic condyloma are
used interchangeably with low-grade squamous intraepithelial
lesion (LSIL), and the terms CIN2 and CIN3/carcinoma in
situ are synonymous with high-grade squamous intraepithelial
lesion (HSIL). The recent conclusions of the Lower Ano-
genital Squamous Terminology (LAST) project, held in
2012, are in line with this.1 The choice of diagnostic ter-
minology (dysplasia, CIN, SIL) is critical only in terms of
the decision point for recommending excision versus
observation. The impact of this terminology on manage-
ment is discussed later in this chapter.
Identifying Patients at Risk for Cervical Neoplasia
In clinical practice, there is no algorithm that will decide
whether a given reproductive-age woman should or should
not have a Papanicolaou (Pap) test, short of clinical evi-
dence of HPV infection, lower genital tract symptoms, or
298
Cervical Cancer Prevention and Management of the Abnormal Papanicolaou Test
Management of ASCUS and Squamous Intraepithelial Lesions
Histopathologic Diagnosis of Preinvasive Disease
Diagnostic Criteria for Squamous Intraepithelial Lesions
Low-Grade Squamous Intraepithelial Lesions
Endocervical Curettage
Resolving Discordant Papanicolaou Test and Biopsy Results
Management of Squamous Intraepithelial Lesions
DIAGNOSIS AND MANAGEMENT OF INVASIVE SQUAMOUS
CELL CARCINOMA
Introduction
Diagnosis of Invasion
Immunohistochemistry
Defining Superficially Invasive (Microinvasive) Squamous Cell Carcinoma
Management of Superficially Invasive Squamous Cell Carcinoma (Stage IA)
Pathology of Invasive Squamous Carcinoma
Treatment and Outcome of Squamous Carcinoma
Management of Squamous Cell Carcinoma
a prior abnormal Pap test. Risk factors classically associated
with cervical cancer—early age of first intercourse, multiple
sexual partners, and increasing parity—are sufficiently
common that a high percentage of women would qualify
for Pap smear screening by these criteria. Moreover, timing
of sexual activity may be as or more important than
absolute number of sexual partners in conferring risk of
current HPV infection.2 The following is a series of risk
factors associated with cervical neoplasia.
The Squamocolumnar Junction
It is understood that the cervix has a tenfold to twentyfold
greater risk of malignancy than other anogenital sites,
including vulva, vagina, and anus. It has long been known
that the great majority of carcinomas arise near the entrance
to the cervix at the squamocolumnar junction (SCJ). This
is due to a unique target cell population at the SCJ that
is absent in these other sites, including the anus (Fig.
13.1). The specific properties of this junction are discussed
later in the chapter.3 Suffice to say that this chapter would
be much shorter if unique SCJ cells did not exist!
Human Papillomaviruses
HPV infection is the etiologic agent for the great majority
of cervical epithelial neoplasms. The powerful association
between HPV infection and cervical neoplasia has been

Abstract
This chapter has been extensively revised to address several
important issues in the field of cervical neoplasia. These
include new information about the origin of cervical
squamous neoplasia and its impact on our perceptions
of lesion development. This leads in to a discussion of
the conundrum of lesion grading, specifically the laboratory
management of lesions that fall between cervical intraepi-
thelial neoplasia grade 1 (CIN1) and grade 3 (CIN3).
Strategies for managing this problem are offered, and the
concept of squamous intraepithelial lesion (SIL) of inter-
mediate (or indeterminate) grade is unveiled. The underpin-
Keywords
cervical intraepithelial neoplasia (CIN)
human papillomavirus (HPV)
p16
squamous cell carcinoma
squamous intraepithelial lesion (SIL)
Cervical Squamous Neoplasia 13
ning of this concept is the absence of any biomarker that
can be depended upon to segregate low-grade squamous
intraepithelial lesion (LSIL) from high-grade squamous
intraepithelial lesion (HSIL) in light of the widespread
variations in interpretation between observers and the lack
of compelling information to support p16 as either a
marker of HSIL or a predictor thereof. Other important
topics include new approaches to superficially invasive
squamous carcinoma, new management schemes, and the
promise of vaccination programs. Finally, the concept of
prophylactic ablation of the squamocolumnar junction
(SCJ) is addressed as another possible approach to cervical
cancer risk reduction in vulnerable populations.
298.e1
 Cervical Squamous Neoplasia 13

A B
Fig. 13.1.  The squamocolumnar junction (SCJ) and cervical neoplasia. A, Tissue section of the junction
of the ectocervical (or mature metaplastic) epithelium with the endocervical mucosa. The arrow highlights
the SCJ. B, Immunofluorescence for cytokeratin 7 (CK7) of a comparable region in another cervix
demonstrates intense staining of a cuboidal cell population at the junction of the ectocervix and endocervix.
This population is postulated to be the origin of cervical squamous and columnar neoplasia.

Prior exposure Squamo-columnar

(antibodies) junction cell Lower-risk types
Condoms Impaired local immunity Immune response

ACIS

Columnar
differentiation
HPV Cell SIL Persistence HSIL Cancer

Viral HPV HLA

load variants HPV Viral 3q25–27
interact integration amplification

High
risk
Centrosome abnormalities
Cell cycle disruption
Genomic instability
Promotor methylation

4 to 24 months

4 months to 5 years

1 to 25 years

Fig. 13.2.   Schematic of human papillomavirus (HPV) infection. ACIS, Adenocarcinoma in situ; SIL,

squamous intraepithelial lesion; HSIL, high-grade squamous intraepithelial lesion; HLA, human leukocyte
antigen.

established, and the accumulated experimental, molecular,
and clinical evidence has left no doubt that HPV directly
influences the pathogenesis of cervical neoplasia. Table
13.1 summarizes the varied incidences of cervical cancer
worldwide. Fig. 13.2 illustrates what takes place locally
in the cervix and the factors involving infection in the
SCJ. Over the past several years, the realization has emerged
that (1) HPV infection is ubiquitous in the young sexually
active population, (2) frequency of infection peaks in the
early reproductive years, (3) infections are transient, often
appearing and disappearing without cytologic abnormality,
but (4) persistent infection by the same HPV type is strongly
associated with risk of a current or subsequent cervical
neoplasm.4,5 The conclusion to this chapter reiterates the
most compelling link between HPV and cervical neoplasia—
that immunization with vaccines derived from high-risk
HPVs will ultimately have a major impact on the prevalence
rates of significant HPV-associated cervical neoplasms.6 It
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 Diagnostic Gynecologic and Obstetric Pathology

Table 13.1  Incidence of Cervical Carcinoma Worldwidea Table 13.2  Classification of Human Papillomavirus Types

Adjusted Adjusted Human

Locale Incidenceb Mortalityb Papillomavirus Cancers (%) Controls (%) Odds Ratio

Worldwide 16.1 8.0 16 50.5 3.3 435

More developed 11.4 4.1 18 13.1 1.3 248

Less developed 18.7 9.8 45 5.5 0.7 198

East Africa 44.3 24.2 31 2.7 0.6 124

Mid Africa 25.1 14.2 52 2.7 0.3 200

North Africa 16.8 9.1 33 1.0 0.1 373

South Africa 30.3 16.5 58 2.3 0.5 115

West Africa 20.3 10.9 35 1.1 0.5 74

Caribbean 35.8 16.8 59 1.3 0.1 419

Central America 40.3 17.0 51 1.0 0.3 67

South America 30.9 12.0 56 0.7 0.4 45

North America 8.3 3.2 39 0.6 0.0 —

East Asia 6.4 3.2 73 0.4 0.1 106

Southeast Asia 18.3 9.7 68 0.2 0.1 54

High-risk: Types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, 82.
South Central Asia 26.5 15.0 Possibly high-risk: Types 26, 53, 66.
Low-risk: Types 6, 11, 40, 42, 43, 44, 54, 61, 72, 81, cp6108.
Western Asia 4.8 2.5 From Munoz N, Bosch FX, de Sanjose S, et al: Epidemiologic classification of human
papillomavirus types associated with cervical cancer. N Engl J Med 348(6):518-527, 2003.
Eastern Europe 16.8 6.2

Northern Europe 9.8 4.0

studies, it is possible to ascertain the relative strength of
Southern Europe 10.2 3.3 association between certain HPV groups and not only
cancer but also preinvasive atypias. Kahn et al. followed
Western Europe 10.4 3.7
women with mild cytologic atypia and correlated the
Australia/New Zealand 7.7 2.7 outcome of CIN3 at 10 years with HPV type.7 The relatively
strong association between HPVs 16 and 18 and CIN3
Melanesia 43.8 23.8 (15% to 18%) versus all other high-risk HPV types (3%)
Micronesia 12.3 6.2
and low-risk HPV types (<1%) is a compelling endorsement
of HPV-16 as the prototypic high-risk type. A more recent
Polynesia 32.9 17.4 study by Castle et al. showed that two high-risk or onco-
a
Data from http://globocan.iarc.fr/old/FactSheets/cancers/cervix-new.asp. genic HPV tests within approximately 1 year conferred a
b
Per 100,000 per year. risk of CIN2+ biopsy at 3 years of 17%, which increased
to 41% for HPV-16 (Table 13.3).8 However, as noted earlier,
infection by HPV-16 is not a guarantee that HSIL will
ensue, and other factors, such as the degree of cytologic
also addresses the potential value of pre-emptive removal abnormality and colposcopic findings, have a major influ-
or destruction of the SCJ. ence on whether HSIL will be found on biopsy.9
Cancer-associated (“high-risk”) HPV types impose a broad The relationships between HPVs and cervical neoplasia vary
gradient of risk, with HPV-16 conferring the greatest risk. both for lesion grade and cell type. HPVs 6 and 11 are not
Low-risk HPV types may confer risk as surrogate markers associated with cervical carcinomas or HSILs. HPV-16 is
of “at-risk behavior.” Nearly 100 HPVs have been character- detected in nearly 50% of HSIL and squamous carcinomas
ized, and more than 40 have been identified in the genital of the cervix and is the “prototypic” cancer-causing virus.
tract. Genital HPVs have traditionally been divided into In contrast, HPV-56 is associated with fewer than 1 in 50
those with low, intermediate, and high association with cancers. HPV-18 is associated with less than 15% of
cervical carcinoma.7 Currently, those HPVs with any squamous carcinomas, predominating in adenocarcinomas
association are termed “high-risk” HPV types. Table 13.2 in situ (ACISs) and invasive adenocarcinomas. Small cell
reviews the types of HPV and the evidence linking them neuroendocrine carcinomas are almost exclusively associ-
to cervical carcinoma. From this information and prior ated with HPV-18. A fourth group, consisting of newly
300

Table 13.3  Follow-Up as a Function of Short-Term
Persistence of High-Risk Human Papillomavirusa
Cervical Intraepithelial
High-Risk Human Papillomavirus Neoplasia Grade 2 + Biopsy
Status (Two Tests) (3 Years)
Negative/negative 0.5%
Negative/positive 3.4%
Positive/negative 1.2%
Positive/positive 17%
HPV-16+/HPV-16+ 40.8%
a
Defined as two positive tests within an average of 1 year.
From Castle PE, Rodríguez AC, Burk RD, et al: Proyecto Epidemiológico Guanacaste
(PEG) Group. Short term persistence of human papillomavirus and risk of cervical
precancer and cancer: population based cohort study. BMJ 339:b2569, 2009.
discovered HPV types and having uncertain or controversial
association with cancer, exists and presumably confers a
low risk of cancer.10
Is there regional variation in HPV type? Prevalence rates
of high-risk HPVs vary somewhat among different regions
of the world and different countries. Nevertheless, HPVs
16 and 18 are the dominant HPVs detected, ranging from
64% to 77% across different continents.11
Does the amount of virus present influence risk? There is
general agreement that higher levels of viral DNA (viral
load) correlate with risk of SIL. However, viral load will
not discriminate LSIL from HSIL, because viral production
is often higher in low-grade lesions.12 For this reason, viral
load is not used as a predictor for HSIL.
Persistent infection by the same HPV type is strongly associated
with risk of cervical neoplasia. The majority of HPV infections
are transient. Only a few cases score positive for the same
HPV type on successive tests. Prospective studies have
shown that persistent infections by the same type correlate
with increased risk of lesion detection, particularly after
cone biopsy, and retrospective studies of patients with
cervical cancer have also documented prior infection and
an association between persistent HPV positivity and
neoplasia.13,14 Studies have shown that more than 90% of
patients who developed smear abnormalities had persistent
high-risk HPV infection.15
Non-Viral Factors
A number of non-viral factors have been implicated in
risk, most of which are not usually taken into account in
clinical management. They include the following:
• Human leukocyte antigen (HLA) type: The evidence
suggests that specific HLA class II haplotypes may
influence HPV antigen presentation and the immune
response to HPV infection, in turn influencing the risk
of developing invasive cervical carcinoma. However,
the precise mechanisms underlying these associations
remain to be clarified.16
• Age: Young, sexually active women are at greatest risk
for HPV infection and preinvasive cervical neoplasia.
Cervical Squamous Neoplasia 13
20
% HPV+
SCC incidence
15
10
5
0
24 29 34 39 44 49 54 59 64
Fig. 13.3.  Distribution of human papillomavirus (HPV) frequency
in the population and cervical cancer as a function of age. A progressive
decline in HPV index coincides with an increase in cancer risk. SCC,
Squamous cell carcinoma.
This risk drops significantly with increasing age, which
is associated with increasing risk of cancer (Fig. 13.3).
Risk drops further with the approach of menopause,
paralleling the drop in HPV prevalence with age. The
progressive drop in risk with age has been attributed
to an effective immune response to the virus that follows
the onset of sexual activity and exposure to HPVs.
Protection is long lasting, given the low rates of HPV
positivity in middle-age women. There is conflicting
evidence regarding HPV rates in older women, but some
studies support a small but distinct increase in positive
rate after menopause.17
• Immune status: Defects in cell-mediated immunity
imposed by transplant therapy significantly increase
the risk of cervical cancer. Human immunodeficiency
virus (HIV)-infected individuals are prone to HPV
infection, persistent HPV infection, and a higher risk
of precursor lesions. The impact of HIV infection on
cervical cancer risk is controversial, but prognosis appears
worse in patients with severe immunodeficiency. HIV
is clearly associated with increased risk of anal cancer
in men.18
Women post-transplant have higher than normal rates
of HPV positivity.19 Cancer rates are higher in this
population, and in general anogenital cancers occur
at a younger age. One study reported a fivefold
increase in risk of HSIL (50% vs. 10%) in transplant
recipients.20 In one study, lower genital cytopathology
was evaluated in 105 immunosuppressed renal
transplant recipients. Evidence of HPV infection was
found in 17.5% and of lower genital neoplasia in
9.5%. The rate of the virus infection in the immu-
nosuppressed was nine times greater than in a general
population and 17 times greater than in a matched
immunocompetent population.21 In one-third of
patients with HPV lesions and half of patients with
neoplastic lesions, multiple lower genital sites were
also involved.
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 Diagnostic Gynecologic and Obstetric Pathology
HIV infection has been the most intensively studied
and permits the breakdown of risk according to
several outcome measures:
• The risk of HPV positivity is increased in women
who are HIV positive. Approximately 60% of
HIV-infected women versus 36% of uninfected
women score positive for HPV, based on testing
of cervical samples. Frequencies of HPV-16,
HPV-18, and multiple infections are also signifi-
cantly more common in the HIV-infected group.22,23
• The risk of persistent HPV infection is significantly
increased in HIV-infected women. Estimates place
the risk of high-risk HPV infection at least twofold
of non–HPV-infected controls, and the risk of
persistent infection is nearly six times higher.
Furthermore, in one study, persistence was 1.9
(95% confidence interval [CI], 1.5–2.3) times
greater than normal if the subject had a CD-4 cell
count greater than 200 cells/µL (vs. less than 500
cells/µL).24
• The risk of a subsequent SIL is significantly
higher in HIV-infected women and viral load
and low CD-4 counts correlate with cytologic
abnormalities.25-27
• The proportion of HSILs appears to be not sub-
stantially higher in HIV-infected women. Ellerbrock
et al. also showed that 91% and 75% of SILs in
the two groups, respectively, were LSILs.25
• The risk of persistent SIL appears higher in women
with HIV, being 76% versus 18% in the study by
La Ruche et al.28
• The incidence of invasive carcinoma is variably
influenced by HIV infection. Three studies reported
up to fifteenfold greater risk in HIV-infected
women.29-31 However, Chokunonga et al. and La
Ruche et al. did not consider HIV a major factor
in cervical cancer incidence in Central Africa.32,33
Another study from South Africa found no sig-
nificant difference between stage of presentation
and HIV status, although some correlation was
observed for patients with CD-4 counts of less
than 200 cells/µL.34
• The male partners: The role of the male partner can be
summarized as follows:
• Sexual history of the male sexual partner influences
risk of cervical neoplasia, both in number of lifetime
sexual partners and sexual practices (unprotected sex
with prostitutes).35,36 One group showed that monoga-
mous wives of husbands who had sexual relationships
both before and during the marriage had a substantial
risk of cervical cancer (relative risk [RR] = 6.9 [CI,
2.3–20.7]).37 However, the degree of risk conferred
by extramarital sexual experiences has varied from
study to study.
• There is little evidence that reinfection of the woman
with the same HPV type influences recurrence. Krebs
and Helmkamp showed that treating the male partner
did not influence the risk of recurrent genital warts.38
The implication of this study is that partners are
not reinfected by the same virus, consistent with a
functioning immune system. Kjaer et al. found that
repeated sexual contacts of the male partner with
302
other women did not increase the risk independently,
whereas a history of genital warts and absence of
condom use did.39
• Condoms protect against HPV infections but incom-
pletely. Winer et al. reported an adjusted hazard
ratio of 0.3 for HPV infection in young women
whose partners always used condoms versus those
who used condoms less than 5% of the time. Thus,
condoms significantly reduce the risk of cervical HPV
infection.40
• Circumcision reduces the risk of infection in the
male partner and his female contacts, producing an
RR of 0.65 in the male. Other infections, such as
syphilis and HIV, are also significantly reduced in
circumcised men.41
• Oral contraceptives: Oral contraceptive pill (OCP) use
modestly increases the risk of cervical neoplasia. A large
meta-analysis postulated an RR of 1.90 with use of
greater than 5 years and a decline in risk with cessation
of use.42
• Smoking: Smoking increases the risk of cervical neo-
plasia. The theoretic basis is presumably the presence
of DNA adducts in the cervical mucus, exposing the
transformation zone mucosa to carcinogens.43 A retro-
spective study in a Nordic population showed an odds
ratio of 2.7 for women with nicotine in their serum
after controlling for the presence of HPV-16/18 antibod-
ies.44 An RR of 1.58 was computed in another study
examining environmental exposure.45
• Chlamydia infection: The association between chlamydia
infection and cervical neoplasia is controversial. Several
studies have shown a relationship between genital infec-
tions and HPV or HSIL.46 Others, however, have not
shown a relationship between antibodies to chlamydia
and cervical neoplasia.47 A recent study showed an odds
ratio for cytologic abnormalities of 10.7 when coinfec-
tion with both chlamydia and HPV was documented.48
• Women who have sex with women: Risk of cervical
neoplasia is increased in women who have sex with
other women. Studies have shown high rates of sexually
transmitted infections in women who have sex pre-
dominantly with other women, although the rates of
genital condylomata were low. However, the risk of
developing HSIL was not determined. Two reports have
shown that CIN2 may occur in lesbians.49,50
In summary, a multitude of factors, viral and host related,
influences risk of cervical neoplasia before, during, and
following exposure and lesion progression. The complexity
of this relationship underscores the importance of addi-
tional risk factors that result in only a minority of women
developing cervical cancer following exposure to HPV.
Human Papillomavirus Testing
As a screening tool, HPV testing has been approved for
cervical cancer prevention, keeping the following in mind:
• HPV positivity increases the risk of cervical neoplasia
fortyfold.
• An abnormal smear plus high-risk HPV confers a 20%
risk of HSIL.
• Consecutive positive high-risk HPV confers an up to
33% risk of HSIL outcome.

• A single positive Hybrid Capture II test, particularly
in young women, has less value. However, the high
negative predictive value of this test, combined with a
normal Pap smear, virtually ensures the patient is free
of a cancer precursor. Testing is superior in sensitivity
to the Pap smears and has emerged as a cost-effective
alternative.51
• Combined negative HPV testing and normal smear may
increase the duration of the “protective effect.” Because
HPV is detected prior to the development of a cytologic
abnormality, it is likely that patients negative by both
HPV testing and smear may be followed at longer
intervals than by smear alone.
• Women under age 20 frequently score positive for HPV,
but many of these infections will resolve; hence the
recommendation that this group not be tested for HPV.4
• The index of HPV positivity drops markedly over age
30, and this group has been selected for screening.
The degree to which an HPV test is more specific for
neoplasia risk in this group varies according to the
study. However, the percentage of women over 30 years
of age who score positive is sufficiently low that HPV
testing is considered a cost-effective adjunct to cervical
cytology.52
• A significant fraction of menopausal women may score
positive for HPV, with the significance of this finding
still unclear. A recent study using a sensitive assay for
detecting HPV found two peaks of HPV DNA preva-
lence, including a first peak of 16.7% in women
younger than 25 years old. HPV DNA prevalence
declined to 3.7% in the age group 35 to 44 years old,
then increased progressively to 23% among women
65 years old and older.53 Another study found the
rates to be lower than the above figure postmenopause
(6.2%), with the frequency of HPV-16 in CIN2+ (29%)
less than half that seen in similar lesions in younger
women.54
• A number of studies have emphasized the importance
of HPV-16 and HPV-18, the two most prevalent HPVs
in cervical cancer, relative to other high-risk HPVs,
particularly the fact that of all the high-risk HPVs, these
two are much more likely to be associated with follow-up
cervical abnormality.55
Current Screening Algorithms
Screening algorithms have undergone a two-step evolution.
The first algorithm proposed a high-risk HPV test (Hybrid
Capture II) in conjunction with cervical cytology for women
over age 30. Women negative with both tests are followed
at 3-year intervals. More recently, with the adoption of
type specific (HPV-16/18) testing as an adjunct and with
the availability of this probe set as a U.S. Food and Drug
Administration (FDA)–approved test, the algorithm has
been improved to permit exclusion of a significant number
of HPV-positive women from immediate follow-up. In
essence, HPV-positive women who score negative for
HPV-16 or HPV-18 can be followed at a longer interval
with HPV testing and cytology. If both are negative, the
patient can return to a 3-year screening interval. If either
is positive, the patient is evaluated further. This approach
takes advantage of the stronger positive predictive value
Cervical Squamous Neoplasia 13
of HPV-16/18 testing.56 The reader can envision that as
time passes, the proportion of women scoring positive
for HPV-16/18 will diminish and the algorithm might
evolve, or other biomarkers will be proposed if they have
a stronger predictive value than HPV testing. At present,
other adjuncts to the Pap smear have not been approved
for screening.
Cytology
A more comprehensive treatise on the cytopathologic
diagnosis of cervical neoplasia can be found in any of
several texts addressing this field. The purpose of this
discussion is to update and integrate several facets of
cytologic screening that have been evolving, are directly
relevant to patient care, and are thus of interest to anyone
involved in the laboratory or clinical management of
cervical neoplasia. These include the following:
• Realistic expectations from cytologic screening: The
majority of squamous carcinomas of the cervix are
preceded by preinvasive SILs. Studies of cancer inci-
dence rates have shown an approximately two-thirds
reduction since the late 1940s and the introduction of
the Pap test. Predictably, the most striking reduction
in rates occurs immediately following introduction of
screening, where a precipitous reduction (from 28 to
four cases per 100,000 in the studies by Bryans et al.)
occurs simply by removing those with occult cancer.57
Once this is accomplished, the incidence drops to a
steady state of approximately four cases per 100,000
and is favorably affected by screening of women at a
young age. According to Miller, the maximum achievable
reduction in cancer by conscientious Pap test screening
is approximately 90%.58
Moreover, since the mid-1980s, there have been progres-
sive declines in the prevalence of and death rate for
cervical cancer, a trend that should continue with
the use of HPV testing in screening algorithms and
the widespread use of papillomavirus vaccines.59
• The Bethesda System for cytologic diagnosis is the
standard for evaluation of cervical cytology since 1988.60
In 2001, the system was refined with the following:
• Eliminating the adequacy category “satisfactory but
limited”
• Combining the category previously termed “negative
and benign cellular changes” into a single “negative”
category
• Renaming atypical squamous cells of undetermined
significance (ASCUS) atypical squamous cells (ASC)
and contracting its subcategories to ASCUS and atypi-
cal squamous cells, cannot rule out HSIL (ASC-H)
• Renaming atypical glandular cells of undetermined
significance (AGCUS) as atypical glandular cells and
contracting its subcategories to atypical glandular
cells, not otherwise specified (AGC NOS) and atypical
glandular cells, favor neoplasia (AGC favor neopla-
sia).61 This has been revised recently in 2014 with
the following minor changes:
• Benign endometrial cells (which conceivably
indicate endometrial pathology) are reported
starting at age 45 rather than age 40.
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 Diagnostic Gynecologic and Obstetric Pathology

• Cytologic preparations with LSIL and a “few
cells suggesting HSIL” are now reported with two
diagnoses, LSIL and ASCUS favor HSIL (ASCH).
This was recommended in order to maintain
the two-tier system and avoid an “intermedi-
ate” category. However, in the opinion of these
authors, the two-tier system will always be an
oversimplification. The reader is referred to the
most recent text, which updates both figures and
recommendations.62,63
Box 13.1 summarizes the most recent Bethesda classifica-
tion system for the interpretation of benign findings and
abnormal squamous cytologic changes.62 (See Table 14.2 for
the classification and reporting of glandular abnormalities.)
Glandular lesions are discussed in greater detail in
Chapter 14, but three issues relating to diagnostic errors
in Pap test interpretation should be mentioned:
• Detection errors are more common with adenocarci-
nomas than squamous carcinomas.
• Adenocarcinomas represent a greater proportion of
cancers now detected in reproductive-age women.
• Adenocarcinomas also constitute the bulk of the
“surprises” that are being encountered in the 20- to
30-year-old group. The latter fact has important

BOX 13.1  The Bethesda System of Cytologic Classification (2014)

Specimen Type Other
Indicate conventional smear (Pap smear) versus liquid-based preparation • Endometrial cells (in a woman ≥45 years old)
versus other (Specify if “negative for squamous intraepithelial lesion”)

Specimen Adequacy Epithelial Cell Abnormalities

• Satisfactory for evaluation (describe presence or absence of Squamous Cell
endocervical/transformation zone component and any other quality • Atypical squamous cells (ASCs)
indicators, e.g., partially obscuring blood, inflammation, etc.) • Of undetermined significance (ASC-US)
• Unsatisfactory for evaluation (specify reason) • Cannot exclude HSIL (ASC-H)
• Specimen rejected/not processed (specify reason) • Low-grade squamous intraepithelial lesion (LSIL)
• Specimen processed and examined, but unsatisfactory for evaluation (Encompassing: Human papillomavirus (HPV)/mild dysplasia/CIN1)
of epithelial abnormality because of (specify reason) • High-grade squamous intraepithelial lesion (HSIL)
(Encompassing: Moderate and severe dysplasia, CIS; CIN2 and CIN3)
General Categorization (Optional) • With features suspicious for invasion (if invasion is suspected)
• Negative for intraepithelial lesion or malignancy • Squamous cell carcinoma
• Other: See Interpretation/Result (e.g., endometrial cells in a woman
≥45 years old) Glandular Cell
• Epithelial cell abnormality: See Interpretation/Result (specify • Atypical
“squamous” or “glandular” as appropriate) • Endocervical cells (NOS or specify in comments)
• Endometrial cells (NOS or specify in comments)
Interpretation/Result • Glandular cells (NOS or specify in comments)
Negative for Intraepithelial Lesion or Malignancy • Atypical
(When there is no cellular evidence of neoplasia, state this in the General • Endocervical cells, favor neoplastic
Categorization above and/or in the Interpretation/Result section of the • Glandular cells, favor neoplastic
report—whether or not there are organisms or other non-neoplastic • Endocervical adenocarcinoma in situ
findings.) • Adenocarcinoma
• Endocervical
• Endometrial
Non-Neoplastic Findings (Optional to Report)
• Extrauterine
• Non-neoplastic cellular variations • NOS
• Squamous metaplasia
• Keratotic changes Other Malignant Neoplasms (Specify)
• Tubal metaplasia
• Atrophy Adjunctive Testing
• Pregnancy-associated changes Provide a brief description of the test method(s) and report the result so
• Reactive cellular changes associated with: that it is easily understood by the clinician.
• Inflammation (includes typical repair)
• Lymphocytic (follicular cervicitis) Computer-Assisted Interpretation of Cervical Cytology
• Radiation If case examined by an automated device, specify device and result.
• Intrauterine contraceptive device (IUD)
• Glandular cells status posthysterectomy Educational Notes and Comments Appended to Cytology
Reports (Optional)
Organisms
Suggestions should be concise and consistent with clinical follow-up guidelines
• Trichomonas vaginalis published by professional organizations (references to relevant publications
• Fungal organisms morphologically consistent with Candida spp. may be included).
• Shift in flora suggestive of bacterial vaginosis
• Bacteria morphologically consistent with Actinomyces spp.
• Cellular changes consistent with herpes simplex virus (HSV)
• Cellular changes consistent with cytomegalovirus
ACIS, Adenocarcinoma in situ; CIN1, cervical intraepithelial neoplasia grade 1; CIN2, cervical intraepithelial neoplasia grade 2; CIN3, cervical intraepithelial neoplasia grade 3; NOS, not
otherwise specified.
From Nayar R, Wilbur DC (Eds.): The Bethesda System for reporting cervical cytology: definitions, criteria, and explanatory notes, ed 3, New York, 2015, Springer.
304
 Cervical Squamous Neoplasia 13

implications (and a mandate) for cancer detection Cytologic Alterations That Are Best Left Out
strategies (HPV testing) that augment the Pap test in of the ASCUS Category
this group of reproductive-age women and the important
role of vaccines, which target the principal HPVs associ- These include the following:
ated with this group of tumors.64 1. Mild superficial cell karyomegaly without hyperchro-
masia: This applies particularly to the changes seen in
Nondiagnostic Squamous Atypia association with menopause or women older than 40
(Atypical Squamous Cells of years old (Fig. 13.4A and B).67
Undetermined Significance) 2. Parakeratosis and anucleated squames: Superficial sheets
of parakeratotic cells may contain mild degrees of
Introduction anisokaryosis (see Fig. 13.4C).68
3. Focal nuclear enlargement in atrophic smears (see
ASCUS connotes squamous abnormalities that cannot be Fig. 13.4D): In the absence of hyperchromasia, pleo-
confidently classified as negative or SIL. ASC interpretations morphic forms, or binucleation, these are best interpreted
carry, in aggregate, an approximate 10% risk of a coexisting as benign cellular changes.
HSIL. Historically, this category received considerable 4. Immature metaplasia with uniform nuclei (see
scrutiny with efforts to subclassify the type of ASCUS.65 Fig. 13.4E)
However, with the advent of highly sensitive HPV testing, 5. Reactive squamous epithelial cells with mild karyomegaly
there is less emphasis on cytologic precision and more should not be interpreted as ASCUS. However, the
on the HPV results. distinction from ASCUS is subjective in such instances
The outcome of studies using HPV testing has demon- (see Fig. 13.4F).
strated two important findings, as shown in Table 13.4:
• The disparity in risk between HPV-positive and HPV-
negative ASCUS is approximately twentyfold (20% vs.
Cytologic Criteria for the Diagnosis of ASCUS
1.1%), in contrast to an ASCUS subclassification system, The term “atypia” as defined by the Bethesda System was
in which the disparity between “favor HSIL” and “favor reserved for cases in which the cellular changes are of
reactive” is only tenfold.66 uncertain significance but suggestive of SIL.69 Inevitably,
• Subclassification of ASCUS does not add significant this category includes cases that ultimately prove to be
value to what is already gained by HPV testing. The inflammatory, reparative, or atrophic changes, as well as
role of HPV testing in managing ASCUS is discussed cases that prove to be SIL. If this terminology is to be
here.61 used, it is critical that alterations such as “benign atypia,”
“inflammatory atypia,” or “reactive atypia” and other
recognizably benign alterations be excluded. Whether
alterations “suggestive but not diagnostic of koilocytotic
Table 13.4  Risk of High-Risk Human Papillomavirus, atypia” should be included depends on whether the
High-Grade Squamous Intraepithelial Lesion, or Cancer as a diagnosis of ASCUS is based on cytoplasmic halos alone.
Function of Cytologic Diagnosis In essence, ASCUS is best applied to those alterations that
raise the possibility of a cancer precursor. It is unlikely
Parameter Reference Outcomea Percentage that mild superficial karyomegaly, cytoplasmic halos, and
normal non-atypical parakeratotic cells qualify as significant
ASCUS 115 HPV(+) 30 to 60 cancer risk factors.
ASCUS 115 HSIL 10
The cytologic criteria for ASCUS are designed to identify
abnormalities that are intermediate in severity between
186 Cancer 0.1 those of clear-cut reactive or reparative processes and SILs.
Nuclear enlargement exceeds that typically associated with
ASCUS (HPV+) 115 HSIL 15 to 27b
known benign proliferations but falls short of SIL; hence,
311 Cancer 0.5 the compromise on 2.5-fold differences in size. Nuclear
hyperchromasia may be greater than normal, but the
ASCUS (HPV−) 115 HSIL 1.1 diagnosis of SIL may not be made, because the nuclei do
not contain coarse chromatin or nuclear membrane
Follow-up smear (−) 115 HSIL 3.7
irregularity, are associated with a low nuclear/cytoplasmic
LSIL smear 311 HSIL 27.6c (N/C) ratio, appear degenerated, or are arranged in regularly
spaced cells more characteristic of a benign process.
LSIL cyt/Colpo (−) 311 HSIL 11.3 Alternatively, the cells may be obscured by inflammation,
311 HSIL 11.7
blood, or drying artifact, forcing a qualification of the
LSIL cyt/Biopsy (−)
diagnosis. Finally, the number of cells may be so few that
LSIL cyt/LSIL biopsy 311 HSIL 13 the cytopathologist is uncomfortable with an absolute
a
Outcomes with follow-up of up to 2 years.
diagnosis.68
b
Varies with length of follow-up and cut-off threshold for HPV positive. ASCUS can be subdivided conceptually into several
c
2-year follow-up. morphologic patterns illustrated in Fig. 13.5. It should be
ASCUS, Atypical squamous cells of undetermined significance; colpo, colposcopy; cyt,
cytology; HPV, human papillomavirus; HSIL, high-grade squamous intraepithelial lesion; stressed that these patterns overlap and may not be
LSIL, low-grade squamous intraepithelial lesion. reproducible, but the reader should be aware of them to
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 Diagnostic Gynecologic and Obstetric Pathology

understand the range of nondiagnostic squamous atypias
and how they may be interpreted. For example, a category
(such as, cells suggesting koilocytosis) may be interpreted
by one cytopathologist as a mimic of koilocytosis and
another as diagnostic. Moreover, superficial cells with mild
cytologic atypia inherently generate less concern than
immature metaplastic cells with atypia, the latter overlap-
ping with HSILs that have a metaplastic appearance.
Atypical superficial cells resembling koilocytes comprise
a pattern of cellular changes, which include cytoplasmic
halos and minor degrees of nuclear atypia (see Fig. 13.5,
A-D). It may be argued that this type of ASCUS is the least
supportable, inasmuch as cytoplasmic halos without
diagnostic nuclei may warrant a diagnosis of reactive
changes only. The spectrum of such changes begins with
reactive changes (such as is seen with trichomoniasis) and
ends with koilocytotic atypia.70,71 Cells containing the classic
irregular densely bordered halos with slight nuclear atypia
fall into the category of ASCUS. Cells without any nuclear
atypia, irrespective of the appearance of the cytoplasmic

A B

C D
Fig. 13.4.   Changes that should not be called atypical squamous cells of undetermined significance

(ASCUS) include: A and B, mild superficial cell karyomegaly in perimenopausal women; C, parakeratosis
without atypia; D, focal nuclear enlargement in atrophic smears; E, immature metaplasia with uniform
nuclei and discrete cell borders; and F, reactive squamous cells.
306
 Cervical Squamous Neoplasia 13

E F
Fig. 13.4, cont’d.

A B
Fig. 13.5.   Cytologic patterns often classified as atypical squamous cells of undetermined significance

(ASCUS) include: A, cells bordering on low-grade squamous intraepithelial lesion (LSIL); B and C, mildly
atypical maturing metaplastic cells; D, atypical parakeratotic cells; E, atypical metaplasia; F, atypical
immature cells with a metaplastic phenotype; G, hyperchromatic clusters of cells with a high nuclear/
cytoplasmic (N/C) ratio; and, H, degenerated atypical cells (less common with liquid-based preparations).
A and D cannot be reproducibly distinguished from LSIL; B, C, and E are least impressive and might
also be classified as reactive changes; F and G were associated with biopsy-proven high-grade squamous
intraepithelial lesion (HSIL) and cervical carcinoma, respectively. Continued

307
 Diagnostic Gynecologic and Obstetric Pathology
C D
F G
Fig. 13.5, cont’d.
halo, would best be classified as reactive, inasmuch as
their contribution to cancer risk is negligible.
Non-koilocytotic nuclear atypia in mature squamous
cells, including squamous metaplasia, is another form of
ASCUS, which typically presents with two- to threefold
nuclear enlargement with mild increases in nuclear chro-
masia and no alterations in nuclear contour (see Fig. 13.5).
The distinction between this form of ASCUS and SIL is
based on the degree of chromatin coarsening or distur-
bances in cytoplasmic maturation.
Atypical immature squamous metaplasia (AISM) poses
a diagnostic problem as a consequence of the small cell
size and hence, higher N/C ratio of metaplastic cells (see
308
E
H
Fig. 13.5E and F). If the nuclear changes are interpreted
to be those of an SIL, the cytology will be that of a high-
grade lesion, almost by definition. For most clinicians,
this will result in more aggressive management.
Key features in AISM include nuclear sizes of 35 to
100 µm, with cyanophilic or granular staining cytoplasm,
N/C ratios generally over 60%, and irregular nuclear
contours. Significant increases in nuclear chromasia are
less likely, particularly in liquid-based preparations. The
cells tend to occur in strings and small groups on con-
ventional smears but are frequently isolated on liquid-based
cytology (LBC) preparations. Because of their small size,
they can be easily overlooked or mistaken for benign

histiocytes, small (reserve) squamous cells, or endometrial
cells. Because of the potential that AISM may accompany,
progress to, or represent an HSIL, Pap smears displaying
this abnormality should be carefully scrutinized. This
pattern is most often reported as ASC-H.
Atypical repair reactions can demonstrate cellular
crowding and overlap (as contrasted with typical repair,
which is in flat sheets) marked variation in nuclear size,
prominent and irregular nucleoli, and irregular chromatin
distribution. Such cases may be difficult to distinguish
from invasive carcinoma and SIL (see Fig. 13.5G). Car-
cinomas often have a tumor diathesis and many isolated
atypical cells, features that are usually absent in repair
reactions.
Regarding squamous atypia in the postmenopausal
patient, it is important to preface the remarks below with
two comments. First, screening is not recommended for
those women with no history of a cervical cytologic
abnormality. Second, if an abnormality is detected, HPV
testing will likely be part of the workup, and the patient
will be managed accordingly. That being said, the patholo-
gist should keep the following in mind:
• Smears obtained from postmenopausal women not
receiving hormone replacement often are air-dried with
apparent nuclear enlargement, a significant inflammatory
component, and clusters of small dark cells, most likely
small “parabasal” cells. A common finding is the appear-
ance of “blue blobs”—degenerated nuclear material,
as well as scattered squamous atypia, may be found.
• Some atypias may resolve with estrogen therapy. Others
may not, yet still not be corroborated with an abnormal
tissue biopsy.
• Squamous atypia in general in older women is less
likely to be followed by a tissue diagnosis of SIL.
Symmans et al. correlated abnormal cervical cytology
and biopsies with HPV DNA detection using in situ
hybridization.72 The rate of HPV detection in pre- and
postmenopausal patients with abnormalities was 50%
and 10%, respectively, with similar disparities in biopsy-
proven disease (46% vs. 17%) indicating a low frequency
of HPV DNA in postmenopausal atypias.
• Kaminski et al. found that a single smear with squamous
atypia in patients older than 50 years old was associated
with CIN or HPV (biopsy diagnoses) in fewer than 5%
of cases.73 Moreover, only 9% with repeat cytologic
abnormalities had a biopsy proven SIL. Thus, non-
diagnostic squamous atypia in the postmenopausal
woman, even when persistent, has a low likelihood of
SIL outcome.74
In summary, squamous atypia in the postmenopausal
period is associated with significant cervical pathology in
a far smaller proportion of cases than in a younger age
group. This seems to hold true even in cases with repeated
atypias; and the “estrogen test,” although helpful in revers-
ing atrophy atypia for a significant number of women,
still resulted in repeat squamous atypia without biopsy-
proven disease in 14%.
On a practical level, postmenopausal women with
squamous atypia in a setting of atrophy should be offered
an estrogen test and repeat smear to check for reversal of
the atypia with epithelial maturation. Colposcopy or biopsy
should be performed in those cases where atypias persist,
Cervical Squamous Neoplasia 13
keeping in mind that some women will continue with
persistent squamous atypia, despite estrogen treatment.
Cohesive sheets or clumps of immature cells, so-called
hyperchromatic crowded groups (HCGs), may describe a
variety of conditions, ranging from benign endocervical,
endometrial, or lower uterine segment epithelial cells to
HSIL, ACIS, and invasive carcinomas. They are discussed
here and in Chapter 14.75
Degenerated atypical cells may produce problems in
interpretation, primarily because the degree of nuclear
irregularity or hyperchromasia may be marked (see Fig.
13.5H). In cases where degenerative changes are clearly
present, in particular when they occur in small numbers
of cells, follow-up smears should be considered. If degenera-
tion appears to be a secondary phenomenon and the
numbers of cells in question are plentiful, colposcopy
should be performed.
Cytologic Criteria for Squamous
Intraepithelial Lesions
Cytologic criteria for squamous intraepithelial lesions
follow the histologic spectrum for early squamous neoplasia
as classically defined. Fig. 13.6 depicts the traditional
histologic categories of CIN1 to CIN3 with some modern
adjustments, the most substantive of which is the com-
bining of CIN1, flat or exophytic condyloma, into the
category of LSIL. Exophytic condylomas are excluded
from CIN1 by many, but this distinction cannot be made
cytologically except when the high-risk HPV test is nega-
tive, as will occur for HPV-6 or HPV-11 associated lesions.
However, for simplicity and ease of management, these
three categories are combined and, by definition, exhibit
principally surface atypia. Progressive loss of epithelial
maturation accompanied by greater nuclear atypia heralds
the transition to CIN2 or CIN3, the latter termed high-grade
squamous intraepithelial lesions (HSILs). The following is a
guideline for translating this concept into cytologic criteria
(Figs. 13.7 through 13.9).
Low-Grade Squamous Intraepithelial Lesions
On cytologic smears, the changes associated with LSIL can
be divided into three types:
• Intermediate or superficial cells with nuclear enlargement
(usually threefold) and hyperchromasia, which sharply
distinguishes these cells from the adjacent normal cells
(see Fig. 13.7A and B): The nuclei exhibit relatively smooth
perimeters and small irregularities in nuclear shape and
contour. Hyperchromasia is present and may take the
form of a finely granular chromatin or uniformly increased
nuclear density with opaque or smudged appearance.
Nucleoli are inconspicuous in both LSILs and HSILs,
excepting those associated with inflammatory change.
• The classic koilocyte: These cells should have enlarged
(twofold to threefold) nuclei, and they are usually
hyperchromatic (see Fig. 13.7A). One defining feature
is a sharply etched perinuclear halo with an irregular
perimeter of dense cytoplasm. Another feature support-
ing the diagnosis of LSIL is nuclear enlargement
and hyperchromasia. Perinuclear halos without any
nuclear enlargement, binucleation, or hyperchromasia
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 Diagnostic Gynecologic and Obstetric Pathology

A B C D E

F G H I J

Normal CIN1 CIN2 CIN3/CIS

(LSIL) (HSIL) (HSIL)
Fig. 13.6.  A classic schematic of cervical intraepithelial neoplasia (CIN; lower) defines the cytopathologic
(A-E) and histopathologic (F-J) transitions from normal to low-grade squamous intraepithelial lesion
(LSIL) (cervical intraepithelial neoplasia grade 1 [CIN1]) to high-grade squamous intraepithelial lesion
(HSIL) (cervical intraepithelial neoplasia grade 2 [CIN2]/cervical intraepithelial neoplasia grade 3 [CIN3]).
This composite addresses the common aspects of histologic-cytologic correlation but does not take into
account nuances of transformation zone differentiation that may further influence morphology (see Figs.
13.23 to 13.27). CIS, Carcinoma in situ.

are not sufficient for a diagnosis of an SIL, inasmuch
as perinuclear halos alone have not been shown to
correlate independently with the presence of HPV.
Binucleation is common in LSIL and is found in
intermediate or superficial cells. Just as with the peri-
nuclear halo, binucleation is more specific for the
diagnosis of LSIL if it is accompanied by some of the
other features, such as nuclear enlargement or
hyperchromasia.
• The most subtle manifestation of LSIL is a change
confined predominantly in the parabasal-type cells. The
degree of parabasal cell atypia may vary, and in smears
containing LSIL, conspicuous atypia is not present. In
immature condylomas (discussed later), cells with a
parabasal/intermediate appearance are most prominent
and show slight nuclear enlargement, slightly more
granular chromatin, and binucleation. We have termed
a subset of such cells “abortive koilocytes” inasmuch
as they exhibit some features of these cells (nuclear
enlargement, indistinct perinuclear halos) but lack the
more striking nuclear hyperchromasia and perinuclear
clearing.
High-Grade Squamous Intraepithelial Lesions
On cytologic preparations, the cells of HSIL (see Fig. 13.8)
display the following:
310
• The abnormal cells are characteristically less mature
and exhibit a higher N/C ratio than those of LSIL.
• Nuclear enlargement is generally in the same range as
in LSILs, but because the N/C ratio is increased, the
cells appear smaller.
• Hyperchromasia, coarse chromatin, and membrane
contour irregularity are all more conspicuous than
in LSIL.
• Architecturally, the cells of HSILs are arranged in two
main patterns: (1) as cohesive groups of cells with
indistinct cell borders (syncytial-like groupings) or
(2) as individual cells arranged in rows or streams.
Small, immature squamous cells and mature keratin-
izing cells with marked nuclear atypia are classified
as HSIL.
The reader can surmise from the previous discussion that
it takes more than just an assessment of cell maturity to
distinguish low-grade from high-grade precursors. The
nuclear abnormalities associated with high-grade precursors
can be appreciated in not only the basal/parabasal cells but
also in intermediate and superficial-type cells. It should be
emphasized that a portion of HSILs will be associated with
low-grade morphology. As many as three-quarters of SIL
lesions of all grades have been reported to contain coexisting
koilocytes.76 From 10% to 20% of LSILs on a Pap test are
confirmed as HSIL on biopsy.77 Moreover, high-risk HPV
types are also associated with LSIL.3 At the practical level,
 Cervical Squamous Neoplasia 13

A B

C
Fig. 13.7.  Cytology of low-grade squamous intraepithelial lesions (LSILs), including koilocytes (A),
and superficial cell karyomegaly and binucleation (B, C). The principal features are variation (and
increase) in nuclear size and chromatin density.

the diagnostic pathologist must always consider the possibil-
ity that an LSIL, even one that closely resembles a condyloma,
may comprise a portion of (or coexist with) a larger lesion
that contains high-grade morphology. Occasionally, a classic
LSIL will merge with a CIN3. These facts must also be
appreciated when interpreting cytology.
One particular presentation that should be noted is HSIL
composed of small, metaplastic-type cells. Some HSILs
are composed of exfoliated small, metaplastic-type cells
with mild to moderate atypias, a correlate of a subset of
similar-appearing lesions on histology.78,79 The extremely
coarse chromatin and bizarre shapes typifying conventional
HSIL are not present. Because of the relatively mild atypia,
the diagnosis of such lesions is poorly reproducible, and
they are often diagnosed as ASCUS or ASC-H, if not
overlooked completely (see Fig. 13.8C and D). The
important features distinguishing this subset of HSIL from
benign metaplasia are the small size of the cells, increased
N/C ratio, and irregularly shaped nuclei. The latter changes
may be subtle.
Differential Diagnosis of Low-Grade and
High-Grade Squamous Intraepithelial Lesion
The following are the most common pitfalls in the diagnosis
of either LSIL or HSIL on cytologic preparations. The reader
should bear in mind that many of the “pitfalls” of cytologic
interpretation also fall under the category of nondiagnostic
squamous atypias:
• Mimics of LSIL include the following: (1) trichomonas
infections with mild perinuclear halos, (2) postmeno-
pausal nuclear karyomegaly (see Fig. 13.9A), and (3)
nonspecific reactive changes leading to mild superficial
nuclear atypia.
• Mimics of HSIL include (1) atrophic changes, which
include a high N/C ratio but greater regularity in
nuclear contour and absence of coarse chromatin (see
Fig. 13.9B and C); (2) sampling of lower uterine
segment, in which syncytial groups of lower uterine
segments may be confused with HSIL; and (3) adeno-
carcinoma in situ, which may also be difficult to
311
 Diagnostic Gynecologic and Obstetric Pathology

B C
Fig. 13.8.   Cytology of high-grade squamous intraepithelial lesions (HSILs), including: A, abnormal

cells with moderate cytoplasm, anisokaryosis, and coarse-appearing chromatin; B and C, similar nuclear
features; and a higher nuclear/cytoplasmic (N/C) ratio.

separate from HSIL (see Chapter 14). Occasionally
immature condylomas may be difficult to distinguish
from HSIL on cytology (see Fig. 13.9D); however, this
dilemma is uncommon.
• Is it LSIL or HSIL? Pitfalls in the diagnosis include
keratinizing lesions, including dyskeratosis or atypical
parakeratosis (Fig. 13.10A-C). Mild surface binucleation
in the absence of hyperchromasia correlates poorly with
LSIL (see Fig. 13.10A). In general, keratinizing cells
consisting of small round to oval hyperchromatic nuclei
with uniform chromatin distribution and binucleation
and plaquelike clusters correlate with LSIL (see Fig.
13.10B and C). Greater disturbances in cellular dif-
ferentiation, characterized by densely hyperchromatic
nuclei, variable keratinization, and increased N/C ratio,
are characteristic of HSIL (see Fig. 13.10D-F). When
the pathologist encounters changes of this magnitude,
312
the diagnosis of HSIL is justified, and it may not be
possible to exclude the potential of invasive carcinoma.
If the changes are of a lesser degree and the distinction
between LSIL and HSIL is not clear, the diagnosis “SIL,
difficult to grade” is appropriate.
Cervical Cancer Prevention and Management of
the Abnormal Papanicolaou Test
Current Guidelines for Screening and Human
Papillomavirus Testing
Presently the following are recommended for the most
cost-effective cervical cancer prevention:
• Pap tests are not performed until age 21.
• Pap tests are performed between age 21 and age 30.
• After age 30, women can be followed by HPV testing
alone.
 Cervical Squamous Neoplasia 13

A B

C D
Fig. 13.9.   Cytologic mimics of squamous intraepithelial lesion (SIL). A, Menopausal karyomegaly

with cytoplasmic halos mimics a low-grade squamous intraepithelial lesion (LSIL). Mimics of high-grade
squamous intraepithelial lesion (HSIL) include, B and C, atrophic changes and, rarely; D, immature
condyloma.

Co-testing with smear and HPV testing versus HPV testing
alone is still being debated.
Management of ASCUS and Squamous
Intraepithelial Lesions
Numerous algorithms, some rather ponderous, have been
established for the management of women with cytologic
abnormalities. The complexity of these algorithms contrasts
with the very low risk overall of developing cervical cancer,
but they reflect the continued fear by all members of the
field at the specter of a missed or undiagnosed cancer or
precursor that could develop in such an accessible site
and eventually kill a woman. This chapter does not list
all of these algorithms, but readers are referred to the
ASCCP website (www.asccp.org). The principles behind
these algorithms include the following:
• High risk HPV-positive ASCUS is typically referred to
colposcopy with two caveats:
• Management of women younger than 21 to 25 years
old with any abnormal Pap test is more conservative
to avoid precipitating a path to unnecessary cone
313
 Diagnostic Gynecologic and Obstetric Pathology

(loop electrosurgical excision procedure [LEEP])
biopsy.
• More refined testing for HPV-16/18 permits a more
conservative approach to high-risk HPV-positive
ASCUS, allowing continued follow-up.
• HPV testing can be taken into account for not only
ASCUS but ASC-H and LSIL. ASC-H and HSIL are always
referred to colposcopy, but as mentioned earlier, a
follow-up interval is permitted in women age 21 to 25.
• Atypical glandular cells are always pursued with care,
although negative HPV testing provides a follow-up
option.
• Follow-up intervals are lengthened to 3 years following
negative HPV and cytologic findings.

A B

C D
Fig. 13.10.   Abnormal parakeratosis and abnormal keratinizing cells. A and B, Binucleation and more

subtle differences in nuclear size and staining intensity in mature cells are generally more common in
low-grade squamous intraepithelial lesion (LSIL). C and D, More pronounced nuclear disturbances with
coarse chromatin raise the possibility of high-grade squamous intraepithelial lesion (HSIL).
314

E F
Fig. 13.10, cont’d. E and F, Striking abnormalities in nuclear contour and chromasia coupled with
dense cytoplasmic keratinization characterize HSIL and may be associated with invasive carcinoma.
Histopathologic Diagnosis of Preinvasive Disease
Expectations From the Clinical Setting
When the clinician sends a biopsy to the pathologist for
a diagnosis, it is usually based on an abnormal Pap smear.
Although the practitioner may expect the biopsy to explain
the abnormality on the smear, approximately 70%, 45%,
and 20% of cytologic interpretations of ASCUS, LSIL, and
HSIL, respectively, will not be verified on cervical biopsy.
The colposcopist should expect this. Explanations for such
discrepancies include clinical sampling error and diagnostic
imprecision, particularly in the interpretation of ASCUS.
The role of colposcopy is to exclude cancer and
assess the transformation zone (Fig. 13.11A-D). In many
cases, the colposcopist will not identify a lesion and will
not perform a biopsy. The pathologist may receive an
endocervical curettage (ECC) only and, again, should
approach this specimen with realistic expectations. The
pathologist must avoid overcalling minor histologic changes
in an effort to achieve consistency between the cytologic
and histologic findings. In turn, the colposcopist should
be wary of cytologic/histologic correlation rates that are
high (over 80%) or diagnoses of SIL that follow negative
or equivocal colposcopic findings.
The pathologist who is interpreting the biopsy should
be aware of the previously described odds of detecting an
SIL and realize several important realities that will be
repeated later in this section:
• That an HPV-positive ASCUS or LSIL diagnosis on
cytology that is confirmed to be LSIL or less on biopsy
carries a 5% to 13% risk at 2 years of HSIL on
follow-up.80,81
• The most important practical issue, following exclusion
of malignancy, is to determine whether the patient has
Cervical Squamous Neoplasia 13
an abnormality in the cervical transformation zone that
requires ablation or surgical (LEEP) removal.
• A woman younger than 25 years old should be managed
with care, particularly if there is a question of whether
her cervical abnormality qualifies as an HSIL or is a
questionable CIN2. The diagnosis of CIN2 imposes a
LEEP excision on fewer patients due to the more recent
guidelines but is subject to a high level of interobserver
discordance. When relegating a patient to LEEP excision,
review of such cases by more than one observer may
be helpful in coming to a therapeutic decision.
Practical Considerations Before Examining the Biopsy
Examination of the cervical specimen requires an under-
standing of four components germane to interpreting
cervical squamous neoplasia:
• Excluding non-neoplastic infections, such as herpes or
chlamydia
• Understanding the transformation zone and the plethora
of benign alterations in epithelial differentiation that
characterize this region
• Applying the criteria for determining whether a lesion
is LSIL, HSIL, or of indeterminate grade
• Understanding the influence of the various differentia-
tion patterns in the region of the SCJ and their influence
on morphology of SILs
Excluding Infections Other Than
Human Papillomavirus
Ostensibly, cervical sampling permits the identification and
qualification of HPV-related cervical neoplasia. However,
the issue of infection by other microbial agents must be
315
 Diagnostic Gynecologic and Obstetric Pathology

A B

C D
Fig. 13.11.  A, Colposcopy photographs of prominent transformation zone in a diethylstilbestrol-exposed
patient. B and C, Low-grade squamous intraepithelial lesions (LSILs). D, Following cryotherapy, the
transformation zone is ablated and reepithelialized with mature squamous mucosa. (Photographs courtesy
of Richard U. Levine and Alex Ferenczy.)

considered when evaluating any cervix. Infections that can
be identified or suspected by histologic examination of the
cervix include herpes simplex viruses (HSVs) (Fig. 13.12A
and B), cytomegalovirus (see Fig. 13.12C and D), Chlamydia
trachomatis (see Fig. 13.12E-G), and, rarely, adenovirus.82,83
HSV should be suspected and excluded in any ulcer, par-
ticularly if it is accompanied by epithelial cell necrosis and
acute inflammatory exudate. The diagnostic cells contain
one or multiple nuclei with either discrete inclusions or
316
smudged (“ground glass”) chromatin and are typically at
the periphery of the ulcer, in the spongiotic epithelium, or
as single desegregated cells. Special stains may be helpful if
the diagnosis is uncertain on morphologic grounds alone.
C. trachomatis infection does not elicit specific epithelial
changes but has been associated with follicular cervicitis
in one report.84 This may not be sufficient to confirm the
association, but we do mention follicular cervicitis and
the possible association when it is encountered.
 Cervical Squamous Neoplasia 13

A B C

D E F

G H
Fig. 13.12.   Infections of the cervix that can be identified morphologically include: A, herpes simplex,

presenting as an ulcer with epithelial necrosis and, B, intranuclear inclusions; C, cytomegalovirus, and,
D, chlamydia, which may be associated with follicular cervicitis. E, Inclusions are best seen by electron 317
microscopy (arrows). F, They contain primary and secondary particles (small and large arrowheads). By light
microscopy, inclusions are extremely subtle (G), but may be identified by immunohistochemistry (H).
 Diagnostic Gynecologic and Obstetric Pathology
The Squamocolumnar Junction and the
Transformation Zone
The cell of origin for this spectrum of squamous and pos-
sibly columnar differentiation resides in or near the SCJ.
Recent work has highlighted a population of cells at the SCJ
that may be important progenitors to the entire spectrum
of cellular differentiation (see Fig. 13.1). Moreover, one
can envision that the spectrum of at-risk epithelium is
derived from this population. Furthermore, it is possible
that the risk of a given epithelium evolving to produce an
HSIL following HPV-16 infection is linked to its location
(i.e., within the SCJ vs. more mature squamous elements
in the transformation zone) (Fig. 13.13).
Based on the work by Herfs et al., the SCJ develops
during fetal and early postnatal life as a result of three
phases:
• A population of p63-positive basal cells emerges beneath
cytokeratin 7 (CK7)-positive embryonic müllerian
epithelium.
• The CK7-positive müllerian epithelium exfoliates as
the squamous differentiation progresses. This process
is virtually identical to what can be seen in microglan-
dular hyperplasia in adults, wherein immature columnar
cells give rise to reserve cells that in turn mature to
form squamous metaplasia.
• The result is a SCJ where mature squamous epithelium
joins a mature tall endocervical columnar population.
However, on close examination, a small monolayer
of cuboidal cells remains at this junction, with a few
cells extending over the leading edge of the squamous
mucosa. These cells have been designated residual
embryonic cells. They are illustrated in red in the
schematic in Fig. 13.14A and in the CK7 and p16
stained section of an early lesion in Fig. 13.14B. The
implication is that these cells, like their embryonic
predecessors, still maintain the ability to undergo
squamous and possibly columnar differentiation (see
Figs. 13.1 and 13.13).3,85
Endocervix J Transformation
(columnar) u zone
n
c (squamous)
t
i
o
n
Fig. 13.13.   Cytokeratin 7 (CK7)-stained section of the transformation zone and squamocolumnar
junction (SCJ). Note there are four different epithelial “targets” for human papillomavirus (HPV) infection,
including the ectocervix, metaplastic epithelium between the ectocervix and SCJ (transformation zone),
the SCJ, and the endocervical epithelium. (From Herfs M, Yamamoto Y, Laury A, et al: A discrete population
of squamocolumnar junction cells implicated in the pathogenesis of cervical cancer. Proc Natl Acad Sci
USA 109:10516–10521, 2012.)
318
The fact that most significant precancerous lesions arise
in the SCJ implies that infection of those cells or their
immediate precursors, either on the surface or in subjacent
crypts, is paramount to the genesis of cervical cancer.
Inasmuch as the progeny of the SCJ cells can evolve to
either mature squamous or columnar mucosa, it is reason-
able to assume that as these cells progressively mature,
the risk of significant neoplasia diminishes. Fig. 13.14A
illustrates a schematic of the SCJ and the transformation
zone, depicting the regions less vulnerable to carcinogenic
HPV infection (ectocervix) and the region most at risk
(SCJ). The evidence for this gradient of vulnerability is
largely indirect but based on the following:
• Reserve cells, which are also produced during embryonic
development and are common more cephalad to the
SCJ junction, as well as in endocervical polyps and
microglandular hyperplasia: None of these sites are
particularly vulnerable to HSIL, suggesting that once reserve
cells are established, their risk of HPV-associated neo-
plastic transformation is reduced.
• Immature squamous metaplasia, like reserve cells, has
a similar distribution yet a very low risk of HSIL away
from the SCJ, suggesting that once squamous metaplasia
ensues, the risk of neoplastic transformation more closely
approximates that of the ectocervical or vaginal mucosa.
• Mature squamous epithelium a few millimeters away
on the ectocervix is particularly resistant to HSIL.
• The risk of HSIL once the SCJ is removed is low. More-
over, most of the recurrences develop on the ectocervix,
implying that the vulnerable SCJ cells do not regenerate.
In particular, once persistent disease is excluded by an
interval without an abnormal smear or the presence of
HPV, the risk of HSIL is exceedingly low.86,87
The aforementioned model supports the notion that
there is a population of cells at the SCJ that could be
destined for both squamous and columnar cell differentia-
tion (metaplasias) that develop in response to inflammatory
stimuli and alterations in pH that occur following the
onset of menarche. The squamous component emerges
Ectocervix
(squamous)
n
ctio
Jun
 HPV Conventional bottom-up
HPV infection/differentiation

SCJ-negative LSIL

Krt7

Novel top-down HPV Expansion of

Infection/differentiation
the SCJ cells
Postinfection

SCJ-positive HSIL p16

A B

C
Fig. 13.14.   A, Schematic of the lesion development in the squamocolumnar junction (SCJ) and transformation zone. This depicts different

scenarios of infection. The traditional mode of infection was via the virus accessing basal cells through defects in the epithelium, typically mature
metaplastic or ectocervical epithelium. In contrast, direct infection of the SCJ leads to outgrowth of infected cells which undergo squamous differentia-
tion. B, Early high-risk infection of the SCJ with partial expansion of cytokeratin 7 (CK7) and p16-positive cells. C, Two high-grade squamous
intraepithelial lesions (HSILs), in two columns. Upper images depict CK7 positivity in the superficial cell layers emblematic of the SCJ cells (arrows).
Middle images depict strong p16 staining in all layers including the surface (arrows). Bottom images illustrate human papillomavirus (HPV) nucleic
acids in the surface cells too. The impression is that the residual SCJ cells are being undermined by outward “top-down” expansion of the HSIL.
(C, From Herfs M, Vargas SO, Yamamoto Y, et al: A novel blueprint for ‘top down’ differentiation defines the cervical squamocolumnar junction 319
during development, reproductive life, and neoplasia. J Pathol 229:460-468, 2013.)
 Diagnostic Gynecologic and Obstetric Pathology

in the reserve cells that are highlighted by p63, which is
recognized in basal cells of skin appendages, myoepithelial
cells in the breast and salivary gland, and sub-columnar
cells in the prostate.88 This gene is critical to the mainte-
nance of stem cell characteristics in squamous epithelium
but in the cervix marks the transition from columnar to
squamous lineage as a reserve cell marker.89,90 This transition
and the squamous epithelium that eventuates from the
expansion of these cells define the transformation zone
(see Fig. 13.13). The transformation zone is delineated
by the squamous epithelium extending over recognizable
crypt epithelia signifying the region where the columnar
cells became replaced by squamous metaplasia. The reader
can imagine two zones of susceptibility, that of the trans-
formation zone and that of the SCJ, the latter more vulner-
able to HSIL following infection by oncogenic HPVs because
the cells have yet to differentiate (see Fig. 13.14).
SCJ cells stain intensely with CK7, a property unique
relative to the mature transformation zone epithelium
and to a lesser degree, the mature endocervical epithelium.
CK7 staining revealed the following in the cervix, sum-
marized and illustrated in Fig. 13.15:
• We discovered that the majority of HSILs in the cervix
stained positive for CK7, suggesting an origin within
the SCJ.3,85 Fig. 13.15C illustrates how many HSILs
contain strong CK7 staining, and this marker highlights
cells on the surface reminiscent of SCJ cells. The impres-
sion is that under conditions that favor neoplastic
expansion of the SCJ cells following HPV infection
(shown in red in Fig. 13.15A) HSILs develop by “top
down” differentiation (i.e., they develop via neoplastic
squamous metaplasia by induction of p63 within the
SCJ population). Consequently, these SCJ cells transition
to a neoplastic population and are both HPV and p16
positive (see Fig. 13.15C). In essence, the process is
identical to what happens during embryogenesis with
the exception that it is driven by an oncogenic HPV.
• In contrast, LSILs are more heterogeneous with respect
to CK7 staining. CK7-negative LSILs tend to be cytologi-
cally bland and appear to arise in mature transformation
zone epithelium or ectocervix. Moreover, these lesions
have a lower risk of HSIL outcome, presumably because
they are not the consequence of direct infection of the
SCJ cells. They also have a lower rate of p16ink4+ and
HPV-16+.91,92
• Unlike their counterparts in the ectocervix or mature
transformation zone, CK7-positive LSILs appear to arise
in the SCJ or in immediate metaplastic progeny. These
lesions may have a higher likelihood of HSIL outcome,
a higher rate of p16ink4+ and HPV-16+. Moreover, we
found that these “LSILs” might generate greater disagree-
ment between observers.92,93
• Thus, we concluded that most HSILs will stain for SCJ
markers and that LSILs arising in the SCJ may be more
problematic diagnostically. However, despite this, lesions
classified as LSIL by multiple observers still had a very low
rate of HSIL outcome. These three groups of lesions are
illustrated in Fig. 13.15.91

LSIL InSIL HSIL

A C E

B D F

SCJ marker Negative Positive Positive

HR HPV+ 50% 100% 100%
HPV-16+ 10% 60% 60%
p16ink4+ 27% 74% 90%
Agreement High Low High
Fig. 13.15.  Lesions emerging from the squamocolumnar junction (SCJ) and transformation zone may
exhibit a range of histologies, and the origin of the lesion will influence histology and consequently,
interpretation. A diagnosis of low-grade squamous intraepithelial lesion (LSIL) in the ectocervix (SCJ-)
(A and B) can be made with good agreement. Similarly a diagnosis of high-grade squamous intraepithelial
lesion (HSIL) (CIN2-3) in the SCJ (E and F, SCJ+) will have a high reproducibility. However, a subset of
lesions in the SCJ will be more problematic (C and D), generating less agreement. We interpret these as
lesions of uncertain or intermediate grade (CIN1-2). Associations with high-risk human papillomavirus
(HR HPV), HPV-16 and p16 staining patterns are enumerated. What is clear is that any lesion arising in
the SCJ is highly likely to contain high-risk HPV and be strongly positive for p16, yet may defy classification
as either LSIL or HSIL. InSIL, Intermediate-grade squamous intraepithelial lesion.
320
 Cervical Squamous Neoplasia 13

additional patterns not accounted for in traditional clas-

Milestones in the Classification of Squamous
Intraepithelial Lesions
SILs are defined as squamous alterations in the cervical
transformation zone that are induced by HPV infection.
Differences in the differentiation level or differentiation
pathway of the underlying mucosa may influence the
morphologic presentation of cervical lesions, leading to
sifications. Lesion categories are summarized in Table 13.5.
The classification and management of SILs has evolved
since the late 1960s.154 This is summarized in Fig. 13.16.
The key points in this evolution are as follows:
• CIN was originally defined as a proliferation containing
atypias in all layers of the epithelium.94 The reader can
imagine that lesions classified as CIN in the 1960s were

Table 13.5  Descriptive Categories of Low-Grade Squamous Intraepithelial Lesion and High-Grade Squamous
Intraepithelial Lesion

Category Descriptors Human Papillomavirus p16 Immunostaining

LSIL CIN1, flat condyloma, mild dysplasia HR (70%) Usually diffuse

Exophytic condyloma LR Negative or patchy

Immature condyloma (papillary immature metaplasia) LR Negative or patchy

Immature flat metaplastic LSIL HR Usually diffuse

HSIL CIN2 or moderate dysplasia HR (45% type 16) Diffuse

CIN3 or severe dysplasia/carcinoma in situ HR (60% type 16) Diffuse

Keratinizing SIL HR Diffuse

HSIL with immature metaplastic phenotype HR Diffuse

Papillary carcinoma in situ HR Diffuse

Adenosquamous carcinoma in situ HR Diffuse

CIN, Cervical intraepithelial lesion; HR, high risk; HSIL, high-grade squamous intraepithelial lesion; LR, low risk; LSIL, low-grade squamous intraepithelial lesion; SIL, squamous
intraepithelial lesion.

1960s Mild Moderate Severe CIS

Follow Cone/hysterectomy

1970–80s Condyloma/CIN1 CIN2 CIN3

Cryotherapy Laser/cone

1990s LSIL HSIL (CIN2) HSIL (CIN3)

Follow LEEP

Future? LSIL HSIL (CIN2)* HSIL (CIN3)

Follow LEEP
Fig. 13.16.  Management of cervical lesions placed in historical perspective. Note that the distinction
of moderate from severe dysplasia became less important when the therapeutic options included cryotherapy
and laser ablation (1970s through 1980s). In contrast, when the therapeutic options included loop
electrosurgical excision procedure (LEEP) versus follow-up, the distinction of cervical intraepithelial
neoplasia grade 1 (CIN1) (low-grade squamous intraepithelial lesion [LSIL]) from cervical intraepithelial
neoplasia grade 2 (CIN2) (high-grade squamous intraepithelial lesion [HSIL]) became more critical and
small differences in interpretation had significant impact on management. However, in the vaccine era
and with the application of biomarkers or new algorithms, CIN2* conceivably may be viewed more
critically to allow for conservative management of a subset of women with this diagnosis. CIN3, Cervical
intraepithelial neoplasia grade 3; CIS, Carcinoma in situ.
321
 Diagnostic Gynecologic and Obstetric Pathology
unlikely to be confused with condylomas of any type.
In fact, the classic treatise by Burkhardt contains no
examples of flat or exophytic condylomas.95 Koss implied
in particular in 1955 that lesions containing koilocytosis
were not technically dysplasias because the basal epi-
thelial cell layers were not atypical.96
• Meisels and Purola and Savia in 1976 popularized the
cervical flat condyloma, which logically became more
prevalent with earlier workup of abnormal cervical
cytology. Meisels assigned the term “atypical condyloma”
to those lesions harboring both koilocytosis and basal
atypias.97-99
• This created for the time being a four-class system, flat
condyloma, CIN1, CIN2, and CIN3, one favored by
the British group.100 Less common exophytic condylomas
were segregated from this classification or lumped with
flat condyloma. We would emphasize that this approach
stays true to the original notion that CIN should not
contain so-called “pure” HPV infections that do not
display atypia in the more basal epithelial layers. The
only caveat is the difficulty in consistently separating
three grades of CIN once flat and exophytic condylomas
have been removed. This is one reason why a three-grade
system now classifies the flat condyloma and related
lesions as CIN1.
• The shift in philosophy for the CIN classification was
facilitated by the Bethesda System for cytologic classifica-
tion, which equated condyloma and CIN1 on cytology.
CIN1, once considered an important precursor, was
“decriminalized” to be combined with condyloma. Thus,
traditional CIN lesions were reduced to two groups,
CIN2 and CIN3, and this concept spread to histologic
interpretation.
• Cryotherapy, used extensively in the 1980s to treat CIN1
and CIN2, was usually replaced by LEEP excision, with
CIN1 lesions relegated to follow-up. This resulted in
CIN2 being the diagnosis that would result in LEEP.101
• Reproducibility of CIN2 has been shown to be poor,
and follow-up studies have shown that up to two-thirds
of CIN2s in young women will regress in 2 years, 40%
in 6 months.102
• Recently the LAST project redefined CIN1 as LSIL and
CIN2-3 as HSIL, with the proviso that CIN2 be managed
conservatively in young women by follow-up when
possible.1
• In addition, as closer attention has been paid to the
SCJ and to immature proliferations using biomarkers
such as p16, it has become clear that the range
of proliferations containing HPV nucleic acids has
expanded. Many of these are immature “metaplastic”
SILs that must be addressed within the classification
system.78
Classification Systems and Approaches to Squamous
Intraepithelial Lesion Diagnosis
In the past edition, the discussion of SILs proceeded with
classification (LSIL vs. HSIL), criteria, and a discussion of
biomarkers (p16ink4, MIB1, etc.) in diagnosis. Since then,
classification has become impacted by several variables:
• Attention to the SCJ has uncovered early forms of SIL
previously underappreciated.
322
• The range of epithelial changes associated with HPV
has expanded further as markers for high-risk HPV (p16)
have been employed.
• An excessive reliance on p16 as a marker to discriminate
not only lesion from no lesion but also LSIL from HSIL
(CIN2).
• The realization that the interobserver reproducibility
for the diagnosis of CIN2 (vs. CIN1) is sufficiently poor
to call into question the significance of a diagnosis of
CIN2 when it is rendered by a single observer.92
• The fact that even an adjudicated CIN2 (one that
multiple observers agree on) carries a 40% likelihood
of resolving in 6 months and an over 60% likelihood
of resolving within 2 years without treatment.102,105
• The accumulative data now show that LEEP excision
carries an increasing albeit variable risk of premature
rupture of membranes and premature labor in subse-
quent pregnancies.103 This management tool is too drastic
for a condyloma or CIN1, which can be managed
by observation alone because of the low risk of HSIL
outcome.81
• LEEP is probably overused, given the distinction of CIN1
from CIN2 is made with variable interobserver reproduc-
ibility. This is the basis for recommendations to employ
a period of follow-up when managing women younger
than 25 years old.
Interobserver Agreement for the Diagnosis of CIN2 Is
Fair at Best
Based on published reports, the interobserver agreement
for the diagnosis of CIN2 is highly variable. Overall, in
one study employing experienced pathologists a unanimous
verdict (based on independent review) of CIN2 was reached
in only 19.4% of cases reviewed, and in 31.6% and 47.5%
of CIN1 and CIN3, respectively.104 In the ASCUS/LSIL triage
study (ALTS), quality control (QC) reviewers downgraded
29% of CIN2 to CIN1 or less.105 In another study, the
diagnosis of CIN2 by initial reviewers was proven highly
unreliable, with two study pathologists agreeing on only
13% and 32%.106 A summary of four studies comparing
interobserver reproducibility for the diagnosis of CIN2
noted kappa values of 0.22 (poor), 0.41 and 0.44 (fair),
and 0.57 (good). The authors noted a high rate of interob-
server agreement for scoring lesions as p16 positive (κ =
0.87–0.91) and that by combining p16 and H&E interpreta-
tion, the kappas ranged from 0.62 to 0.75. The implication
was that the presence of p16 positivity facilitated the
diagnosis of CIN2.92
In our practice, relatively inexperienced pathologists had
good agreement on CIN1 or CIN3 with kappa values of
approximately 0.67. However, agreement on CIN2 was
fair with values of 0.22.
Association Between p16 Immunostaining
and SIL Grade
There is a consistent association in the literature between
“strong” p16 immunoreactivity and either HSIL or the
presence of a high-risk HPV type. Sano et al. noted that
over 98% of high-risk HPV infections exhibited diffuse
p16 staining, usually defined as linear strong staining.107
Subsequent reports noted positive staining from 64% to
100% of HSILs, the lesser estimate possibly an artifact

created by the lack of a clear biologic distinction between
strong and diffuse and strong but focal staining.86,109 Stain-
ing frequencies of LSILs have varied as a function of the
frequency of associated low-risk versus high-risk HPVs.
Klaes et al. and Sano et al. noted no diffuse staining in
low-risk HPV infections or associated LSILs.108 Klaes et al.
observed that 87% of LSILs associated with high-risk HPV
exhibited diffuse staining. Herfs et al. noted lower rates
of p16 positivity in CK7-negative LSILs versus CK7-positive
lesions, but this appears to reflect differences in association
with high-risk HPVs between the two groups.91 Overall,
approximately a low estimate of one-third to a high estimate
of two-thirds of LSILs stain strongly for p16.3
Predicting Cervical Intraepithelial Neoplasia
Grade 2–Positive Outcome of p16 and/or
Cytokeratin 7–Positive Low-Grade Squamous
Intraepithelial Lesion
A number of reports tracking the histologic outcome of
CIN1 cases stained with p16 noted a distinctly higher
frequency of CIN2-3 on follow-up.109,110 In these studies,
from 10.3% to 35.4% of p16-positive cases had an HSIL
outcome. In contrast, a much narrower range of p16-negative
LSILs (0%–4.4%) had an HSIL outcome. Several studies
showed the association between p16 and HSIL outcome
to be either of arguable significance or not significant.
One found no differences in risk, but the HSIL outcome
for both groups was inordinately high. Another found
p16 only predictive of an HSIL outcome in the first year
of follow-up. Another found a significant association
between p16 and HSIL outcome but it was not corroborated
in multivariate analysis.111 One study found no significant
association between p16 positivity and HSIL outcome. In
that study, the HSIL outcome for p16 positive and negative
LSILs was 15.0% and 9.4%, respectively. In our experience,
it was 10.3% and 5.7%, respectively.92
Two notable observations from the literature pertain to
interstudy predictions of HSIL outcome from p16 staining
and observer agreement. Sagasta et al. summarized sensitiv-
ity, specificity, and positive and negative predictive values
for p16 staining as predictors of HSIL outcome based on
prior reports.113 Respective ranges for these parameters were
59 to 100, 37 to 72, 10 to 35, and 90 to 100. The most
consistent finding across all of these studies was the negative
predictive value for HSIL outcome of a p16-negative LSIL
(90–100).
If the reader surveys most of the studies that address
“progression,” he or she will note that very few illustrate
entry and exit (outcome) histology. Given the lack of
illustrations in most studies and the lack of reproducibility
across multiple observers for the diagnosis of CIN2, it is
easy to speculate that making claims of progression from
CIN1 to CIN2 is a hazardous exercise when evaluating
the value of any biomarker, such as p16 or CK7. Moreover,
the magnitude of the association may be insufficient to
validate the biomarkers as predictors of outcome. This
seems to be the case in the more recent studies evaluating
both p16 and CK7.93,108,112,113
The lack of clarity regarding the diagnostic criteria
for—and significance of—CIN2 begs the question as to
whether this diagnosis has any real value in the current
management of women with preinvasive cervical neopla-
Cervical Squamous Neoplasia 13
sia.20 There are three valid reasons for questioning the use
of this diagnostic term:
• There is much greater reproducibility in separating CIN3
from CIN1.107
• There is a high rate of short-term resolution for lesions
classified as CIN2.
• There is the recent widespread adoption of the terms
LSIL and HSIL to connote lesions with different risks
of cancer outcome.2
These facts leave the practitioner with several options
for managing cervical biopsies with suspected SIL:
• Classify the lesions as LSIL or HSIL and rely on a second
observer to confirm a suspected lesion at the low end
of HSIL (CIN2).
• Rely on p16 staining to adjudicate the diagnosis of
borderline lesions, classifying p16 positive cases as CIN2.
• Apply strict criteria for the diagnosis of LSIL and HSIL,
reserving a “gray zone” for lesions that cannot be
diagnosed as HSIL with confidence. Lesions in the gray
zone would be classified as SIL of intermediate (or
indeterminate) grade (INSIL). This term would connote
lesions in the CIN1 to CIN2 category. The reader might
take issue with this, inasmuch as the accepted diagnostic
term is CIN2. However, if this entity cannot be diagnosed
reproducibly and if the biomarker used (p16) does not
predict outcome with any degree of precision, a term
reflecting this uncertainty (CIN1 or CIN2) has merit.
The discussion later of diagnostic criteria for SIL will
be made with an appreciation of this conundrum.
Diagnostic Criteria for Squamous
Intraepithelial Lesions
The diagnostic approach to SILs involves not only address-
ing the distribution and quality of the atypias but also
the maturation of the epithelium. This discussion addresses
first the more conventional patterns followed by the
“immature metaplastic” patterns. In both groups, we will
segregate them into obvious LSIL and HSIL and illustrate
a group that is more problematic, so-called “intermediate
grade” SILs.
Low-Grade Squamous Intraepithelial Lesions
The diagnosis of LSIL presumes the presence of high- or
low-risk HPV infection that produces a degree of cytologic
atypia that falls beneath a threshold for worrisome changes
that might herald an HSIL or higher. The diagnosis requires
first excluding benign mimics of LSIL, which is discussed
later. The second step is to confirm the presence of the
characteristic cytologic atypia.
The features of LSIL in mature squamous epithelium
include the following (Fig. 13.17):
• Conspicuous superficial cell atypia with binucleation,
twofold nuclear enlargement, and variable nuclear
chromasia
• Generally low N/C ratio in maturing epithelial cells
with preserved cytoplasmic differentiation
• A subtle expansion of the lower third of the epithelium,
signifying a mild delay in epithelial cell maturation
• A range of nuclear features in the lower third of the
epithelium that includes either euchromasia or uniform
323
 Diagnostic Gynecologic and Obstetric Pathology

Ectocx/Mature TZ SCJ/Immature TZ

Normal

Low

High
A B

C D

E F
Fig. 13.17.   Flat mature low-grade squamous intraepithelial lesions (LSILs) (cervical intraepithelial

neoplasia grade 1 [CIN1] or flat condyloma). A, Schematic. B and C, Variable parabasal cellularity with
orderly maturation and superficial cell atypia (koilocytosis). D, Atypia in the lower third can occur but
is within maturing keratinocytes. E and F, Basal cells are uniform with nucleoli and uniformly distributed
chromatin. SCJ, Squamocolumnar junction; TZ, transformation zone.

hyperchromasia, with minimal variation in nuclear size
and shape: Enlarged nuclei in the lower layers usually
have minimal chromatin complexity and reside within
cells undergoing cytoplasmic maturation.
• Generally well-preserved polarity with uniform transi-
tions to mature epithelium
324
• Exophytic lesions associated with HPV-6/11 will exhibit
patchy or negative p16 staining
• Most flat lesions will exhibit diffuse p16 staining in
the lower epithelial layers
As outlined, the category of LSILs comprises those lesions
in which the stigmata of “classic” CIN—including high

mitotic index, parabasal atypia, loss of cell polarity, abnor-
mal mitoses, and marked disturbances of maturation—are
not present or less pronounced. Presumably, a low- or
high-risk HPV may be present but does not produce criti-
cal biologic changes in the replicating (lower) epithelial
layers. This group of lesions can be subdivided into four
overlapping categories. A sixth category—lesions falling
between LSIL and HSIL—will also be discussed, inasmuch
as these lesions are inevitably encountered in practice.
LSIL patterns include the following:
• Flat mature LSIL (flat condyloma or CIN1): The first
category of LSIL consists of the flat condyloma (CIN1),
which exhibits features similar to condyloma acumi-
natum but lacks the exophytic or papillary growth
pattern (see Fig. 13.17). The degree of epithelial matura-
tion and koilocytosis may vary, but there is minimal
nuclear hyperchromasia and pleomorphism in the lower
Ectocx/Mature TZ SCJ/Immature TZ
Normal
Low
High
A
C D
Fig. 13.18.  Exophytic mature low-grade squamous intraepithelial lesion (LSIL) (condyloma).
A, Schematic. B to D, Exophytic growth with orderly maturation and koilocytosis. SCJ, Squamocolumnar
junction; TZ, transformation zone.
Cervical Squamous Neoplasia 13
third of the epithelium. In contrast to exophytic/papillary
lesions, flat condylomata are frequently associated with
intermediate- and high-risk HPV types. For this reason,
they will usually exhibit diffuse immunostaining with
p16.
• Mature exophytic LSIL (exophytic condyloma, condy-
loma acuminatum): Exophytic condylomata are less
common in the cervical transformation zone and, when
present, are associated strongly with HPV types 6 and
11 (Fig. 13.18). As defined earlier, these lesions exhibit
acanthosis, verruciform growth pattern, and viral
cytopathic effect (koilocytotic atypia). The verrucous
pattern is typified by blunt papillae, in contrast to the
slender filiform papillae of immature condyloma
(discussed later). The superficial atypia is characterized
by karyomegaly, nuclear enlargement with binucleation,
irregularities in nuclear membrane, and hyperchromasia.
B
325
 Diagnostic Gynecologic and Obstetric Pathology
These lesions closely resemble vulvar condylomata but
with more conspicuous cytopathic effect. Because of
their association with low-risk HPVs, exophytic LSILs
will usually stain weakly or negative with p16.
• Extensive exophytic LSIL (“giant condyloma”): An
uncommon but important variant of exophytic con-
dyloma is extensive or “giant” condyloma of the cervix.
These lesions present clinically as a large tumor of
the cervix and distal vagina. This entity can be mistak-
enly classified as a malignancy (verrucous carcinoma),
because it may exhibit a minimum of koilocytosis (Fig.
13.19). The reader is cautioned that any extensive
well-differentiated verruciform lesion in the cervix in
a young woman should be approached with this pos-
sibility in mind. However, we have also encountered
extreme examples of large condylomatous lesions of the
cervix that contained low-risk HPVs yet had invaded
A B
C
Fig. 13.19.  A, Extensive (giant) cervical condyloma showing a bulky exophytic architecture. At higher
magnification the exophytic papillae are devoid of atypia (B) and the growth is nondestructive, with
extension into endocervical crypts (C).
326
or metastasized (illustrated later in Fig. 13.53). These
are extremely rare, however.
High-Grade Squamous Intraepithelial Lesions
Histologic Criteria
HSILs (Figs. 13.20 and 13.21) exhibit atypia in all layers
of the epithelium similar to those classically defined as
CIN. In essence, the extent and degree of nuclear atypia
exceed the limits of that described in flat or exophytic
condylomas (LSIL). These features include the following:
• In general, less maturation, higher nuclear density, and
a less orderly transition from the immature to mature
epithelial layers
• Abnormal cell differentiation
• Greater differences in nuclear size and staining as well
as contours and chromasia in the lower epithelial layers:
In essence, these features reflect the effects of oncogenic
 Cervical Squamous Neoplasia 13

Ectocx/Mature TZ SCJ/Immature TZ

Normal

Low

High
B
A

C D
Fig. 13.20.   High-grade squamous intraepithelial lesions (HSILs) with maturation. A, Schematic. Types

of HSIL include, B and C, well-differentiated or koilocytotic lesions with prominent basal atypia (cervical
intraepithelial neoplasia grade 2 [CIN2]), and, D, keratinizing lesions. SCJ, Squamocolumnar junction;
TZ, transformation zone.

papillomaviruses on the biology of the replicating (lower
epithelial) cell layers.
• In addition to a broader distribution of nuclear atypia
and loss of cell polarity, these lesions are distinguished
to some degree from LSIL by increased mitotic index
and abnormal mitotic figures. CIN3 lesions (including
carcinomas in situ) contain full-thickness nuclear atypia.
However, the degree of variation in nuclear size, contour,
and staining may vary, giving rise to variants of CIN3
that closely mimic immature metaplastic epithelium,
with more subtle degrees of karyomegaly or anisokaryo-
sis. Such cases may be difficult to recognize on both
cytologic and histologic examination, and other strate-
gies (such as, the use of biomarkers) may be required
to distinguish them from inflammatory or reparative
metaplastic changes.
HSILs can display a range of maturation, but a constant
feature is full or near full-thickness atypia.
327
 Diagnostic Gynecologic and Obstetric Pathology
Ectocx/Mature TZ SCJ/Immature TZ
Normal
Low
High
A
Fig. 13.21.   Schematic (A) and a lesion (B) fulfilling the criteria for cervical intraepithelial neoplasia
grade 3 (CIN3) (or carcinoma in situ). SCJ, Squamocolumnar junction; TZ, transformation zone.
Squamous Intraepithelial Lesions of Intermediate
(Indeterminate) Grade (CIN1-CIN2)
If there is one fact that most pathologists agree on, it
is that deciding what falls between CIN1 and CIN3 is
difficult to determine. In our experience, among relatively
inexperienced pathologists, the degree of agreement for
CIN2 is fair at best. This problem comes up when
attempting to identify a threshold for CIN2. The transi-
tion to HSIL is based primarily on the presence of
sufficient atypia in the latter that does not fit within
the spectrum of a flat or exophytic condyloma. One
approach is to focus on the lower epithelial layers, where
the progenitor cell population is derived and contains
the cells that are most likely to confer a diagnosis of
HSIL in a cytologic preparation. Fig. 13.22 compares
the lower half of the epithelium in six lesions. The first
(see Fig. 13.22A) is a typical flat condyloma (LSIL). The
next (see Fig. 13.22B) is another LSIL with some expan-
sion of the basal layer but without any change in nuclear
features. The third (see Fig. 13.22C) depicts lower layers
with somewhat more hyperchromasia but with preserved
polarity, minimal nuclear variation, and without nuclear
overlap. This fits best with LSIL although some might
consider it indeterminate (CIN1-CIN2). In Fig. 13.22D,
there is now nuclear overlap, hyperchromasia, and greater
variations in nuclear size. This would likely be interpreted
as either indeterminate or CIN2. Fig. 13.22E and F depict
irregular nuclear spacing, nuclear overlap, large nuclei,
loss of polarity, and so on, features most would classify
as CIN2 (HSIL). From these photomicrographs, the
reader can appreciate the futility of trying to draw a
sharp line between LSIL and CIN2 (HSIL). It is the most
cogent argument for having a three-grade system, LSIL
(see Fig. 13.22A and B), HSIL (see Fig. 13.22E and F),
and SIL of intermediate or indeterminate grade (CIN1-
CIN2; see Fig. 13.22C and D).
328
B
Fig. 13.23A-C shows additional examples of lesions that
might be difficult to classify as either LSIL or HSIL. A
common theme with these cases is greater cellularity than
typically seen in LSIL and less maturation, yet preservation
of polarity, inconspicuous mitotic activity, and uniform
nuclear morphology with uniform chromatin distribution
and relatively little nuclear overlap.
Squamous Intraepithelial Lesions With a Predominate
Metaplastic Phenotype
The aforementioned LSILs, intermediate SILs, and HSILs
comprise a spectrum that is most often illustrated in the
major texts. In those lesions, maturation usually parallels
grade (i.e., loss of maturation usually but not always heralds
the presence of HSIL). In contrast, lesions arising within
or presenting as an immature metaplastic epithelium can
be more problematic, inasmuch as the degree of cytologic
atypia may be mild and at odds with the lack of cellular
maturation. Like the more traditional SILs, this group may
appear low or high grade once the degree of atypia is
taken into account; they may also be problematic and
many may fall into an indeterminate group. Virtually all
of these lesions will contain high-risk HPV and will be
strongly positive for p16 with the exception of the so-called
“immature condyloma.” This entity is discussed first, after
which we address the spectrum of flat immature metaplastic
lesions.
Immature Exophytic Low-Grade Squamous
Intraepithelial Lesion (Immature Condyloma,
Squamous Papilloma, Papillary Immature Metaplasia)
Immature condylomas fall into the third category of LSIL
variants (Fig. 13.24). Conceptually, immature condylomas
may be viewed as an infection of transformation zone epi-
thelium by low-risk HPV types (6 or 11) that fails to mature
 Cervical Squamous Neoplasia 13

A B

C
D

E F
Fig. 13.22.  A spectrum of changes in the lower layers of squamous intraepithelial lesions (SILs).
A and B (low-grade squamous intraepithelial lesion [LSIL]) and E and F (high-grade squamous intraepithelial
lesion [HSIL]) would likely generate reasonable agreement among pathologists. C and D are more
problematic.

and maintains a phenotype closely resembling immature
metaplasia. Because the atypia in mature condylomas is a
function of viral cytopathic effect and because viral cyto-
pathic effect depends on maturation, immature condylomas
will manifest with the degree of atypia usually seen in
the immature cell layers of a condyloma, which is mild.
Immature condylomas as described are virtually identical
to those variously described as squamous papilloma and
papillary immature metaplasia. Conceivably, some of these
lesions may also be termed transitional papillomas. These
lesions present as a spectrum and are illustrated in Fig.
13.24A-D. Patterns of immature condyloma include the
following: (1) a close similarity to squamous metaplasia
with (a) mild increases in N/C ratio, (b) preservation
of nucleoli, (c) slight nuclear crowding, and (d) a near
absence of keratinocyte maturation; (2) the formation of
small filiform papillae, which is pathognomonic; and (3)
frequent preservation of overlying columnar cell layers, a
pattern that is characteristic of a metaplastic process. Some
of these features fall within the description of “papillary
immature metaplasia.” Like exophytic condylomas, imma-
ture condylomas contain HPV types 6 and 11, meriting
definition as immature variants of these lesions. They will
stain weakly or negative for p16 and typically display a
low to moderate MIB1 index with sparing of the upper
epithelial layers. However, the reader must be aware that
occasional lesions associated with high-risk HPV infections
might mimic immature condylomas; an example is shown
in Fig. 13.24E. Moreover, it is important to distinguish
immature condyloma from papillary carcinomas in situ
and papillary carcinomas. The latter exhibit a high mitotic
index, as well as greater nuclear atypia (see Fig. 13.24F).
329
 Diagnostic Gynecologic and Obstetric Pathology

A B

C
Fig. 13.23.  A to C, Squamous intraepithelial lesions (SILs) difficult to grade are typically more hypercel-
lular and demonstrate less maturation than typical low-grade squamous intraepithelial lesions (LSILs)
but exhibit less nuclear overlap, anisokaryosis, and variations in chromatin staining and complexity than
high-grade squamous intraepithelial lesions (HSILs). These are truly lesions of uncertain or “intermediate”
grade.

Immature Flat Metaplastic Squamous
Intraepithelial Lesions
Because most lesions arising in the cervix do so near the
SCJ, they are by definition “metaplastic” in their origin.
However, depending on the degree of atypia and matura-
tion, many have been overlooked prior to the age of p16
immunostaining. They are also less well understood being
largely near the SCJ and often containing high-risk HPV
types. Thus their diagnosis should be made with this
in mind.
Immature Metaplastic Low-Grade Squamous
Intraepithelial Lesions
These lesions contain features similar to immature con-
dylomas described in the prior paragraphs:
• They contain a higher nuclear density throughout the epi-
thelium. This usually distinguishes them from uninfected
metaplastic epithelium, but the reader must be aware
330
that strong p16 positivity can sometimes be encountered in
metaplastic epithelium with minimal atypia (Fig. 13.25A
and B). In such cases, a descriptive diagnosis or one of
“LSIL in immature metaplasia” is appropriate.
• Nuclei should be evenly spaced without overlap, and
the nuclear chromatin should be similar to uninfected
cells. Small nucleoli, similar to those seen in immature
condyloma, are usually conspicuous.
• In some cases, columnar cell differentiation will be
appreciated in the upper epithelial layers (see Fig.
13.25C). However, the level of atypias is distinct from
that of a high-grade lesion with columnar differentiation
(Fig. 13.26E and F).
• The lesions will stain strongly for p16, but the MIB1
index is usually modest (refer to Fig. 13.28, later). The
columnar cells are often p16 positive as well, in keeping
with their contribution to the lesion. In essence, the
lesion may exhibit both squamous and columnar
differentiation.
 Cervical Squamous Neoplasia 13

Ectocx/Mature TZ SCJ/Immature TZ

Normal

Low

High
B
A

C D

E F
Fig. 13.24.   Immature exophytic low-grade squamous intraepithelial lesion (LSIL) (immature condyloma).

A, Schematic. B and C, Papillary architecture at low magnification. D, At higher magnification the epithelium
is composed of uniform spaced nuclei with small nucleoli and infrequent mitoses. The p16 staining
(inset) will be patchy or negative. E, A squamous intraepithelial lesion (SIL) variant resembles immature
condyloma but has strong p16 staining (right inset) and greater nuclear atypia (left inset). F, High magnifica-
tion of papillary squamous carcinoma. Note the conspicuous nuclear atypia and high mitotic activity.
SCJ, Squamocolumnar junction; TZ, transformation zone.

331
 Diagnostic Gynecologic and Obstetric Pathology

Ectocx/Mature TZ SCJ/Immature TZ

Normal

Low

High
B
A

C D
Fig. 13.25.   Flat immature low-grade squamous intraepithelial lesion (LSIL). A, Schematic. B and

C, Metaplasia with minimal or mild atypia that might be classified as reactive by some. D, Another
example with some columnar differentiation. Insets depict strong p16 staining, consistent with high-risk
human papillomavirus (HPV) infections in the region of the squamocolumnar junction (SCJ). We
would classify these lesions as LSIL within immature metaplasia. TZ, transformation zone.

Immature Metaplastic High-Grade Squamous
Intraepithelial Lesions
These lesions resemble their low-grade counterparts, with
a high nuclear density but with the following features:
• There is greater variation in nuclear size and staining
with less conspicuous nucleoli and more opaque or
granular chromatin (see Fig. 13.26C and D).
• Nuclear density is higher, and there is some nuclear
overlap.
• p16 will be strongly positive; MIB1 index will be
elevated usually with greater than 50% of nuclei staining
positive.
Metaplastic High-Grade Squamous Intraepithelial
Lesion With Columnar Differentiation
It is not uncommon to encounter columnar differentiation
in SILs, often as more superficially arranged vacuoles. These
cells may signify displaced non-neoplastic columnar cells,
but in some instances superficial columnar differentiation
accompanies a lesion that is otherwise classified as SIL.
332
One variant, which is discussed in Chapter 14, is a stratified
mucin-producing intraepithelial lesion (SMILE). These
lesions contain a uniform distribution of vacuoles, giving
a honeycomb appearance. Although they resemble HSIL
by their growth pattern, we interpret them as variants of
adenocarcinoma in situ particularly because of their strong
association with coexisting conventional ACIS. Because
these stratified mucin-producing intraepithelial lesions are
typically seen in association with both HSIL and ACIS,
they suggest a “transition” between the two. We classify
them as ACIS, stratified variant. In our experience, the
frequency of coexisting invasion appears increased in the
presence of stratified ACIS, although the absolute risk is
unknown.113
Metaplastic Squamous Intraepithelial Lesions of
Intermediate Grade (CIN1-CIN2)
Given that the distinction between a low- and high-grade
SIL with a metaplastic growth pattern may be difficult
enough to make, it goes without saying that determining
 Cervical Squamous Neoplasia 13

Ectocx/Mature TZ SCJ/Immature TZ

Normal

Low

High

B
A

C D

E F
Fig. 13.26.   Metaplastic high-grade squamous intraepithelial lesion (HSIL). A, Schematic. B, HSIL

occurring in immature metaplastic epithelium. C, The proliferative index (MIB1) is high. D, Another
immature metaplastic HSIL. E and F, Stratified mucin-producing intraepithelial lesions. These are stratified
variants of adenocarcinoma in situ that overlap histologically with metaplastic variants of HSIL. The
mucicarmine stain of the lesion in F highlights the diffuse distribution of mucin in the epithelium. SCJ,
Squamocolumnar junction; TZ, transformation zone.
333
 Diagnostic Gynecologic and Obstetric Pathology

A B

C D
Fig. 13.27.   Squamous intraepithelial lesions (SILs) in metaplastic epithelium that may be difficult to

classify (cervical intraepithelial neoplasia grade 1 [CIN1] to cervical intraepithelial neoplasia grade 2
[CIN2]). A, An expanded population of uniform-appearing immature metaplastic cells. This case had a
low proliferative index. B, Another immature metaplastic proliferation falling between CIN1 and CIN2.
C, This proliferation is more in keeping with CIN2 but is still quite uniform in appearance. D, A metaplastic
SIL populates a prior region of microglandular change.

the “middle ground” between these two entities would
seem impossible. Suffice it to say that this spectrum is
challenging, but the images in Fig. 13.27 illustrate prolifera-
tive lesions that show an increase in cellularity but are
difficult to pigeonhole as to grade.
This category encompasses some of the entities previously
popularized by Ma et al., who termed them eosinophilic
dysplasia.114 They suggested classifying these lesions as HSIL,
but depending on the nuances of cytology, this type of
lesion may be more suited for a diagnosis of “indetermi-
nate” grade. In essence, these lesions are characterized by
uniform populations of immature metaplastic epithelial
cells that maintain a mildly increased nuclear density
throughout the epithelium and a mild degree of aniso-
karyosis. The more subtle lesions in this category could
easily be misclassified as reactive squamous metaplasia.
This is a problematic diagnostic area because the pathologist
must distinguish two types of “metaplastic dysplasia,” one
that exhibits mild atypia and can be followed (LSIL; see
334
Fig. 13.25 and 13.28A) and the other that exhibits greater
nuclear density and atypia that may be more difficult to
pigeonhole into an LSIL or HSIL. As shown in the figures,
this decision can be difficult.
Another form of problematic lesion is that which occurs
in the setting of small microglandular expansions of
metaplastic epithelium (see Fig. 13.27D). The pattern
closely resembles early squamous metaplasia in areas of
microglandular change, with a lobular or nesting arrange-
ment of immature squamous cells, preservation of cyto-
plasmic maturation, and mucin droplets. The mitotic index
is low, and the nuclei are evenly spaced with minimal
crowding but exhibit prominent karyomegaly with mul-
tinucleation. The characteristic features include a lack of
reduction in nuclear density in the upper layers, the
appearance of a syncytium of nuclei in the superficial
epithelium, and nuclear hyperchromasia. Occasionally
they may undermine intact columnar mucosa or otherwise
resemble reserve cells, recapitulating reserve cells.
 Cervical Squamous Neoplasia 13

A B

C D
Fig. 13.28.  A, A problematic proliferation looks like a squamous intraepithelial lesion (SIL) but is
difficult to characterize. B, The p16 stain is strong. C, However, the MIB1 index is low, arguing against
high-grade squamous intraepithelial lesion (HSIL). D, This inflamed epithelium contains considerable
atypia. However, it is p16 negative (inset) in keeping with either low-grade squamous intraepithelial
lesion (LSIL) or a reactive atypia.

Immunohistochemistry (Table 13.6) • p16ink4, a cyclin-dependent kinase inhibitor, is the

Because we rely primarily on histologic criteria and because
p16 is not sufficiently specific for HSIL or HSIL outcome
to warrant its routine use in management, we use biomark-
ers sparingly. This discussion is limited to MIB1 and p16,
because they are the ones most likely to be used in a
practical sense.
• Generic cell cycle proliferative marker (Ki-67) is typically
confined to the suprabasal cells of the lower third of
normal mucosal epithelium. The presence of Ki-67–posi-
tive cells in the upper epithelial layers is characteristic
of HPV-related SIL, which induces cell cycle activity in
these cells.115 Thus, Ki-67 staining may be helpful in
distinguishing reactive epithelial changes from LSIL or
HSIL, or atrophic mucosa from HSIL. However, denuded
inflamed epithelium often has a high proliferative index.
Moreover, the distinction of LSIL from non–HPV-infected
mucosa is of marginal significance given the nearly
identical follow-up algorithm.
most reliable marker, being expressed strongly in lesions
associated with intermediate- and high-risk HPV types,
in contrast to low-risk HPV infection. Although this
marker will not discriminate LSIL from HSIL, it has a
high negative predictive value (i.e., if negative the lesion
is highly unlikely to be HSIL). The following are gener-
ally true about p16 immunostaining:
• Intense continuous p16 staining characterizes SIL
and usually signifies an HPV type in intermediate
or high-risk group.
• Patchy or weak p16 staining is less specific, particu-
larly if present in mildly atypical epithelium.
• Low-risk HPV infections exhibit a distinctly different
pattern, with concentration of staining in superficial
cell and koilocytic nuclei, implying a link to viral
replication.
• In the vulva and skin, p16 has been associated with
non–HPV-related proliferations, a phenomenon that
may reflect the relationship between p16 and cell
335
 Diagnostic Gynecologic and Obstetric Pathology

As mentioned earlier, staining of reactive changes (such

Table 13.6  Differential Diagnosis of Squamous
as, microglandular change) will stain focally positive
Intraepithelial Lesions
(Fig. 13.30).
Category Mimic Distinguishing Features
Differential Diagnosis of Squamous
Intraepithelial Lesions
LSIL Mucosal polyp (vaginal) Minimal acanthosis, no
koilocytosis
Mimics of Low-Grade Squamous
Intraepithelial Lesion
Reactive epithelial Mild superficial karyomegaly, The reader is reminded that the distinction between LSIL
changes occasional binucleated and non-lesional epithelium has little significance, because
intermediate cells the risk of HSIL outcome in 2 years is approximately the
Postmenopausal Superficial cell karyomegaly, same (5% to 13%). We do not employ special stains to
changes cytoplasmic halos resolve these minor conundrums but keep in mind the
potential mimics of LSIL. A variety of mature epithelial
HSIL Immature reactive/ Basal hyperchromasia, uniform alterations may mimic koilocytosis and are illustrated in
repair nuclear spacing and nuclear
contour, nucleoli
Figs. 13.31 and 13.32 and summarized in Table 13.7. They
include the following:
Immature metaplasia Uniform maturation, minimal • Filiform mucosal excrescences of the vagina (see Fig.
surface hyperchromasia 13.31A): These are discussed in Chapter 11 but are
revisited because of their frequent inclusion with cervical
Atrophy No mitoses, uniform
chromasia, nuclear density biopsies. These are essentially plicaform mucosal polyps
and are no more likely to harbor HPV nucleic acids
Atypical atrophy Enlarged nuclei, uncommon than normal squamous epithelium.117
• Reactive epithelial changes (nonspecific): Occasionally,
Implantation site Uniform and wide nuclear
spacing, bizarre nuclei reparative or reactive epithelial changes will undergo
incomplete maturation, in which case, nuclear hyper-
Endometrial histiocytes Small indented nuclei, granular chromasia will be present in association with the
cytoplasm, lack of polarity cytoplasmic halos. The most important discriminating
HSIL, High-grade squamous intraepithelial lesion; LSIL, low-grade squamous feature is absence of variation, in either cell size or
intraepithelial lesion. staining intensity, in the cell population (see Fig.
13.31B-D). Binucleated cells may or may not be present
but will usually be inconspicuous.
• Postmenopausal squamous atypia (see Fig. 13.32A
cycle arrest. This is an issue with severely inflamed and B): Prior reports have identified cells resembling
epithelia or epithelia undergoing repair irrespective koilocytes in postmenopausal women.118 This spectrum
of site (see Chapter 6). Staining is typically patchy. includes maturation disturbances with “pseudokoilo-
• Endocervical columnar epithelium, including micro- cytosis,” transitional metaplasia, and classic atrophic
glandular change, often stains focally and intensely for changes. In some instances, all three may be present
p16, a phenomenon that must be kept in mind when in the same biopsy. Pseudokoilocytosis is character-
interpreting stains. The reader is encouraged to always ized by epithelial maturation, cytoplasmic halos, and
correlate morphology with p16 immunostaining.116 variable (usually mild) alterations in nuclear size or
• Disparities in staining, in both immature metaplastic staining. Occasionally, binucleation is present, and
epithelium and atrophy, where p16 is positive and the process may closely mimic koilocytosis. In some
the Ki-67 index was very low or no HPV is detected, cases, peripheral condensation of pale cytoplasm
can occur. In such cases, it is probably best to issue an around the uniform halos will give a target-like or “fried
explanatory note and make recommendations based egg” appearance to the cells. This pattern is similar
on the level of morphologic atypia and coexisting to that produced by navicular cells in pregnancy and
clinical and cytologic findings. Mild atypias that stain postpartum.
modestly for p16 are best given a descriptive diagnosis
and managed by follow-up cervical cytology. Differential Diagnosis of Squamous Intraepithelial
As discussed previously in this chapter, we do not recom- Lesion of High or Indeterminate Grade
mend the regular use of p16 or MIB1 to either classify SIL With the advent of biomarkers such as p16, most of these
or predict SIL outcome. We use these markers sparingly conundrums can be resolved with an immunostain when
and under the following scenarios: necessary. The entities that might be encountered include
• Resolving the status of atypical immature metaplastic the following:
proliferations regarding HPV origin (see Fig. 13.28A-C) • Reactive/reparative changes can be difficult when there is
• Addressing the neoplastic potential of some inflamma- hypercellularity and little epithelial maturation present;
tory atypias (see Fig. 13.28D) however, if one or two layers of normal superficial
• Distinguishing atypical atrophy from SIL within atrophy cells can be ascertained, the process is usually benign.
(Fig. 13.29A-F) Prominent nucleoli, regular nuclear spacing, and absence
• Determining if a squamous neoplasm is more or less of marked anisokaryosis or surface cell multinucleation
likely to be derived from the cervix characterize reactive changes (Fig. 13.33A).
336
 Cervical Squamous Neoplasia 13

A B

C D

E F
Fig. 13.29.   Atypia in the atrophic setting. A, This cervical biopsy in a postmenopausal woman contains

atrophy with mild squamous atypias. B, The p16 stain is negative (patchy). C, The MIB1 index is low,
in keeping with atrophic changes. D, Another atypia in the setting of atrophy. E, It is strongly p16 positive.
F, The MIB1 index is slightly increased. This would be classified as a squamous intraepithelial lesion
(SIL) in of uncertain grade.

337
 Diagnostic Gynecologic and Obstetric Pathology

• Immature squamous metaplasia is usually not difficult
to distinguish from HSIL, but excluding SIL may be
difficult when there is an increased nuclear density, in
which case an SIL is likely (see Fig. 13.33B and C). This
can be resolved with an immunostain for p16 (see Figs.
13.28 and 13.29).
• Artifacts that induce nuclear enlargement and hyper-
chromasia as a function of the thermal injury are
common, particularly in LEEP specimens. Importantly,
the enlargement is typically uniform and not accom-
panied by anisonucleosis or nuclear crowding (see
Fig. 13.33D and E).
Fig. 13.30.   Focal nonspecific staining for p16 in microglandular change.
• Atrophic changes include the following, apart from the
pseudokoilocytic changes noted earlier:
• Conventional atrophy with immature but cytologically
bland morphology (Fig. 13.34A and B)
• Atrophy with partial maturation and focal nuclear
enlargement or conspicuous nuclear hyperchromasia
(see Fig. 13.34C)
• Highly cellular lesions with mitotic activity that signify
a coexisting HSIL (see Fig. 13.34D). Features common
to atrophic processes include:
• Hyperchromatic but generally uniform nuclei
• Frequent elongated and sometimes grooved nuclei
• Absence of conspicuous atypia in the upper
epithelial layers
• Absence of mitotic figures
• Atrophic epithelia with partial maturation and
enlarged atypical nuclei comprise one of the more
difficult categories, and distinction from SIL is based
on even spacing of nuclei with conspicuous intercel-
lular bridges and an absence of mitotic activity.
• Radiation effect can involve both the endocervical and
squamous epithelial cells. The prominent changes
include nuclear enlargement and hyperchromasia
associated with abundant cytoplasm, uniform nuclear
spacing with minimal crowding, a low mitotic index,
and evidence of cytoplasmic degeneration with vacuoles
(see Chapter 11). The nuclear chromatin is often
indistinct or smudged, in contrast to the coarse chro-
masia associated with neoplasia. The preservation of a
N/C ratio is important.
• Alterations due to nonsquamous epithelium include
placental implantation site (see Fig. 13.34E). These are
much less common than seen in the endometrium but
are sufficiently distinctive that misdiagnosis is unlikely

Table 13.7  Biomarkers in Laboratory Management of Biopsies

Problem Biomarker Notes

Atrophy versus SIL MIB1 Staining of >30% nuclei or upper layer staining in keeping with SIL

Reactive versus SIL p16ink4 p16 more reliable. MIB1 will stain most of the epithelium but will diminish in the superficial cell layers of reactive
changes.

R/0 SIL p16ink4 Diffuse and often intense staining in immature layers of SILs associated with high-risk HPVs but will also stain at
least 50% of LSILs and many subtle metaplastic atypias
Lesions associated with low-risk HPVs stain variably.
Will stain endocervical cells variably and strongly, including polyps and microglandular change.
More recent studies do not support p16 as either a predictor of LSIL progression or for separating LSIL from HSIL.

CK7 Stains squamocolumnar junction (SCJ).

CK7-positive LSILs have a slightly higher rate of HSIL outcome but the stain is not useful for predicting.
One study suggested that CK7-negative LSILs might have a very low HSIL outcome.

Squamous p63 Intense staining of squamous carcinomas; negative or weak differentiation

Weak in poorly differentiated adenocarcinomas and versus other small cell neuroendocrine carcinomas

Implantation site HLA-G, Intense staining of trophoblast, inhibin variable but specific
versus CIN/carcinoma inhibin
CIN, Cervical intraepithelial neoplasia; CK7, cytokeratin 7; HPV, human papillomavirus; HSIL, high-grade squamous intraepithelial lesion; LSIL, low-grade squamous intraepithelial lesion;
SIL, squamous intraepithelial lesion.
338
 Cervical Squamous Neoplasia 13

A B

C D
Fig. 13.31.   Differential diagnosis of low-grade squamous intraepithelial lesion (LSIL), including mucosal

polyps (vaginal) (A), mild disturbances in maturation (B), mild nuclear irregularity with cytoplasmic
halos associated with inflammation (C, D).

once the pathologist has some experience with this
lesion. The implantation site usually presents as an
eosinophilic (by virtue of the abundant keratin-positive
matrix), irregularly contoured process in the superficial
cervical stroma that is punctuated by scattered hyper-
chromatic nuclei. On closer examination, the irregular
margins of the lesion are composed of a series of small
rounded borders, and the atypical nuclei are separated
by abundant pale to eosinophilic matrix. Occasionally,
these lesions may present as plaquelike lesions resem-
bling intraepithelial lesions. An immunostain for inhibin
will be positive and distinguish this from squamous
epithelium.119 Endometrial macrophages (see Fig. 13.34F)
are another phenomenon that may mimic squamous
lesions. The distinction from an epithelial neoplasm is
based on the small size of the cells, the small slightly
vesicular nuclei, granular cytoplasm without distinct
boundaries, and a feathering of the peripheral line of
demarcation without a sharp basal lamina. Mitoses may
be present, and eosinophils are common. Rarely, a
marked macrophage response to prior injury (cautery)
can mimic a squamous neoplasm (see Fig. 13.34G).
339
 Diagnostic Gynecologic and Obstetric Pathology
A B
Fig. 13.32.   A and B, Menopausal-related changes can be associated with cytoplasmic halos (fried-egg
cells) mimicking koilocytosis.
Endocervical Curettage
ECC is typically used on three occasions:
• During the initial colposcopic evaluation
• At the time of LEEP excision
• During follow-up after excisional therapy
Because a diagnosis of HSIL now requires a LEEP or
cone biopsy, the precise role of the ECC in managing
women with HSIL is less well defined than previously
when the ECC would dictate whether the patient received
cryotherapy or a cone biopsy. In the reproductive-age
woman with a satisfactory colposcopic examination, the
ECC is rarely unexpectedly positive. However, the results
of the ECC appear to have some prognostic significance.
Kobak et al. found that no patients with negative ECC
on initial colposcopy had invasive disease on the final
conization specimen, whereas all of those with invasion
had positive ECC.120 Other studies have corroborated the
value of ECC in ruling out disease in the endocervical
canal so that conservative ablation therapy can be con-
sidered.121 Another option is the endobrush, although this
may be associated with a higher false positive rate.122
Currently, a common scenario is the negative ECC that is
unaccompanied by a biopsy, usually following a negative
colposcopic examination for an HPV-positive ASCUS smear.
In this setting, the ECC is principally for reassurance.
Our approach to the ECC is to classify them as (1)
fragments of benign endocervix, if deemed adequate, (2)
scant fragments of endocervix if only a few small fragments
are seen in a few fields, and (3) no endocervix or essentially
no endocervix identified if endocervix is absent or confined
to rare epithelial cells.
Fragments of LSIL can be classified as “LSIL, detached
fragments” (Fig. 13.35A). Polarized strips of higher-grade
neoplastic epithelium can be classified as strips of neoplastic
340
epithelium consistent with HSIL or HSIL detached frag-
ments (see Fig. 13.35B). Large papillary, irregular or poorly
oriented fragments of neoplastic epithelium should be
classified as strips of neoplastic squamous epithelium,
with the disclaimer that squamous cell carcinoma cannot
be excluded (see Fig. 13.35C) or, if severe, simply classified
as fragments of squamous carcinoma (see Fig. 13.35D).
Resolving Discordant Papanicolaou Test and
Biopsy Results
As discussed previously, lesion heterogeneity or sampling
issues may result in discordance between the Pap test and
biopsy (Fig. 13.36A-F). Resolving these discrepancies is
important prior to proceeding to LEEP or cone biopsy.
Common scenarios are as follows:
• The Pap is abnormal and the biopsy shows no lesion.
This occurs in approximately 15% and 40% of HSIL
and LSIL Pap tests, respectively. If review of the Pap
confirms the discrepancy, follow-up is necessary. A
significant minority of these cases will be proven to
have a lesion on a subsequent evaluation. HPV testing
is of limited value unless the cytologic diagnosis comes
into question.
• The Pap shows LSIL, but the biopsy is HSIL. This occurs
in 10% to 20% of LSIL smears. The cause is usually
sampling artifact, which can be “vertical” (sampling
only the surface cells) or “horizontal” (sampling only
a portion of the lesion) (see Fig. 13.36A-C). Management
is dictated by the severity of the histologic lesion. In
some instances, the cytologic discrepancy is the product
of coexisting low- and high-grade lesions. In most
instances, when such lesions are present in continuity,
they are derived from the same HPV infection. In a
minority of cases, two distinct HPV infections may
 Cervical Squamous Neoplasia 13

A B

C D

E
Fig. 13.33.   A to C, Illustrate immature squamous proliferations that raise the possibility of a squamous

intraepithelial lesion (HSIL). A, Reactive changes exhibit a reduction in nuclear density with minimal
nuclear atypia on the surface or slightly more hypercellular features with readily apparent cytoplasmic
maturation and distinct cell borders. B, High surface nuclear density with less apparent cell borders or,
C, surface hyperchromasia is consistent with SIL in this context. D, Benign cauterized epithelium can be
problematic. E, Lesional epithelium can usually be distinguished by greater surface nuclear density and
anisokaryosis in the latter.

341
 A B

C D

E G
Fig. 13.34.   Differential diagnosis of high-grade squamous intraepithelial lesion (HSIL). Spectrum of atrophic atypia, including conventional

atrophy with variable maturation (A, B), atrophy with mild atypias. C, Atypical atrophy. D, A squamous intraepithelial lesion (SIL) in the setting
342 of atrophy. E, Implantation site trophoblastic tumor, mimicking SIL. F, Sheets of histiocytes can be confused with an epithelial lesion. G, Reactive
changes and histiocytes at a biopsy site.
 Cervical Squamous Neoplasia 13

A B

C D
Fig. 13.35.  A, Strips of detached LSIL in detached LSIL in the endocervical/endometrial sampling.
B, Thin polarized strips of neoplastic epithelium from an HSIL; C, fragments of papillary neoplastic
epithelium cannot be guaranteed to come from a noninvasive squamous neoplasm; D, fragments of
squamous carcinoma are shown for comparison.

produce two lesions. Fig. 13.36D-F illustrates two

instances where two HPV infections—one high- and
one low-risk—coexist in the same area.
• The Pap shows HSIL but the biopsy shows LSIL. This
is an uncommon discrepancy but one that requires
careful review of the cytology and is associated with a
substantial risk of subsequent HSIL. If the cytology is
confirmed as HSIL, the cervical lesion should be carefully
reviewed. Again, a small number of these discrepancies
can be attributed to coexisting low- and high-risk HPV
infections. It is particularly important that when faced
with a cytologic diagnosis of HSIL the pathologist
carefully avoid the overdiagnosis of LSIL on histology.
Such a diagnosis can be particularly confusing, because
it may mislead the clinician into assuming LSIL is present
when in fact the HSIL has eluded sampling.
Management of Squamous
Intraepithelial Lesions
The current guidelines for managing biopsy proven SIL
are available on the ASCCP website and are summarized
in the following sections.
Management of Low-Grade Squamous
Intraepithelial Lesion
LSIL is managed by observation only. Follow-up may be
by either HPV DNA testing every 12 months or with cervical
cytology obtained every 6 to 12 months. If LSIL persists
for more than 2 years, then ablative treatment is an option,
as is continued observation. Therapeutic intervention is
particularly discouraged in adolescence. In a recent study,
Cox et al. found that the 2-year outcomes of HSIL following
(1) a biopsy diagnosis of LSIL, (2) an LSIL-positive smear
with a negative biopsy, and (3) an HPV-positive ASCUS
that was colposcopically negative were from 11% to 13%.123
In our experience, the follow-up HSIL rate (confirmed by
review) is less than 10%.81
Lesions associated with HPV-6 and HPV-11 confer
essentially no direct risk of cancer and relatively little but
not negligible surrogate risk. Low-grade intraepithelial
lesions associated with intermediate- and high-risk HPV
types have a high rate of spontaneous regression and
empirically low risk of progressing to invasive carcinoma.
Recent studies are consistent with the fact that many LSILs
spontaneously regress.
343
 Diagnostic Gynecologic and Obstetric Pathology

A B

E F

Fig. 13.36.   Papanicolaou (Pap) smear/biopsy discrepancies may be produced by vertical sampling

error defined as cytologic sampling (A) of the surface of well-differentiated high-grade squamous
intraepithelial lesion (HSIL) (B), and horizontal sampling error in which multiple grades are present in
the horizontal plane (C). Immature condyloma (low-grade squamous intraepithelial lesion [LSIL]; D)
merges with HSIL (E, right). F, Note the differences in Ki-67 staining (insets). Coexisting LSIL (HPV-II)
and adenocarcinoma in situ (right, HPV-16).

344

Invasive cancers are rarely associated with a histologic
diagnosis of LSIL. We have seen three cases of LSIL cytology
followed by cancer. One was a keratinizing lesion that
was underdiagnosed, the second was a case of koilocytosis
accompanied by some cells diagnostic of moderate dys-
plasia, and the last was a CIN1 concurrent with invasive
carcinoma. Thus, only one of the three was a “bona fide”
LSIL. However, as mentioned earlier, classic LSILs, including
condylomata, may be associated with HSIL as a conse-
quence of either progression or two coexisting HPV
infections. Recognizing this, the practitioner should use
caution when following LSILs that have been preceded by
a cytologic diagnosis of HSIL.
Invasive carcinomas rarely follow LSIL and are almost
always preceded by HSIL. Studies investigating the first
abnormal smear preceding cervical cancer have found that
more than 80% contain CIN3 (severe dyskaryosis), even
as long as 20 years before the diagnosis of invasive carci-
noma. As mentioned earlier, koilocytosis uncommonly is
present on smears immediately predating cancer and, when
present, is associated with younger age, which calls into
question its etiologic significance in such cases.
In essence, conservative management of women with
LSIL diagnosis on biopsy requires that (1) the biopsy
correlates with the Pap smear, (2) the biopsy findings
correlate with the colposcopic impression, and (3) follow-
up can be ensured. Ablation must be considered if a
subsequent smear displays a persistent LSIL (more than
1 year) or higher-grade lesion that is verified by colposcopic
examination.
Management of High-Grade Squamous
Intraepithelial Lesion
Patients with HSIL (CIN2 and CIN3) are treated with
either an excisional procedure (such as, cone biopsy or
LEEP) or by an ablative procedure (such as, cryotherapy
or CO2 laser). An acceptable alternative for HSIL in ado-
lescents and patients in their early 20s would be follow-up
for up to 24 months and treatment only if the HSIL persists.
Ablative procedures are only acceptable in patients who
have an adequate coloscopy and in whom invasive cancer
has been ruled out. Some authors also suggest that ablative
procedures be limited to patients with a negative ECC.
Cold knife cone biopsy has long been the gold standard
for the treatment of HSIL, because it can reliably rule out
an occult invasive carcinoma. Because it is generally
performed in an operating room with general or regional
anesthesia, conization is more expensive than a LEEP,
which can be performed as an office procedure with local
anesthesia. If the margin status is critical (e.g., a patient
with known microinvasive carcinoma), a cold knife cone
is preferred. Between ablative procedures, cryotherapy is
preferred because the equipment is less expensive than
for a CO2 laser, and it can be performed without anesthesia.
Cryotherapy was widely employed in the 1970s and 1980s
but has largely been replaced in the United States by the
LEEP. CO2 laser vaporization is appropriate for the same
patients in whom cryotherapy might be considered. Because
of equipment costs and the need for anesthesia, laser
vaporization is more expensive than cryotherapy. Laser
Cervical Squamous Neoplasia 13
vaporization is uniquely applicable for patients with HSIL
extending into the upper vagina. All of these techniques
have comparable success rates, and success is influenced
by appropriate patient selection.
Management of Young Women (Age 21 to 25)
Three issues emphasize the importance of managing
younger women with greater care. First is the importance
of ensuring that the diagnosis of CIN2 or greater is correct,
given the potential for interobserver disagreement. The
second is the potential impact of treatment on fertility
and pregnancy outcome. A meta-analysis showed an
association of cold knife cone with prematurity, low birth
weight, and increased cesarean section rate.124 LEEP was
shown to increase the rate of prematurity and of premature
rupture of the membranes. Laser ablation was not associated
with an increased risk of adverse pregnancy outcomes.
There was insufficient data to evaluate cryotherapy in this
meta-analysis, but it seems unlikely that cryotherapy would
have a greater effect on pregnancy than would CO2 laser
ablation. All methods of treatment have the potential for
causing infertility related to cervical stenosis or inadequate
cervical mucus production, but there are no reliable
comparative studies. The third issue is the absolute risk
of a cancer outcome in women who are followed after a
diagnosis of CIN2. In our experience and that of others,
at least 40% of consensus (agreement by at least two of
three observers) CIN2 or CIN3 in women from 14 to 25
years old will regress in 6 months, with up to 71% of
CIN2 regressing in adolescents alone.102 In one study, we
encountered one case in 150 HSILs reviewed. In another,
we found none in 300 cases reviewed of women under
age 25 (Crum & Lee, unpublished). However, it should
be emphasized that nearly 50% of young women with a
consensus diagnosis of CIN2 are HPV-16 positive; if their
concurrent cytology is HSIL, the rate is over 60%.125
Therefore, the decision to spare some of these women a
LEEP or cone biopsy must be made not only based on
age alone but also in the context of their cytologic and
colposcopic findings and the degree of certainty that the
patients can be safely followed.
Ablative Procedures (Electrical Excision, Loop
Electrosurgical Excision Procedure or Large Loop
Excision of the Transformation Zone, Cone Biopsy,
or Cryocautery)
Management of the Loop Electrosurgical Excision
Procedure Specimen
Processing and Interpretation
LEEP specimens may come in one or several fragments,
well oriented or impossible to reconstruct. The prosector
must identify the mucosal surface and section each fragment
perpendicular to the long axis. Margins should be desig-
nated only where a cautery artifact can be identified (Fig.
13.37A and B). Thus, there are basically three options in
reporting margins: (1) involved, (2) uninvolved, or (3)
not amenable to evaluation because of distortion or exces-
sive cautery artifact. If the lesion extends to an edge but
the edge does not contain thermal artifact, margin involve-
ment is not confirmed (Fig. 13.38A-C).
345
 Diagnostic Gynecologic and Obstetric Pathology

A B
Fig. 13.37.   A, Sectioning of loop electrosurgical excision procedure (LEEP) specimens. Intact specimen

and, B, following serial sectioning in a clockwise orientation.

A B C
Fig. 13.38.   A, Margins seen in loop electrosurgical excision procedure (LEEP) specimens include

normal cauterized edge. B, Cauterized edge with high-grade squamous intraepithelial lesion (HSIL).
C, Edge with HSIL that has no cautery present. The latter is not interpreted as a margin.

Interpretation of the Endocervical Curettage
The purpose of performing an immediate posttreatment
endocervical evaluation is to assist in determining the risk
for recurrent or persistent disease and to delineate endo-
cervical pathology. The magnitude of its contribution to
management has diminished with the advent of LEEP,
more conservative management, and the use of HPV testing
346
to manage follow-up. Salient points concerning the ECC
include:
• When performed at the time of excisional surgery, ECC
has been shown to have excellent correlation with
conization histopathologic results and negative predic-
tive value, particularly when conization margins are
negative as well.126,127

• A positive ECC at the time of conization is also predictive
of residual disease in the hysterectomy specimen.
• The main limitation of ECC in this application is its
potential for contamination with ectocervical cells, yield-
ing a false-positive result and decreasing its specificity.
• A positive ECC at conization increases the risk of invasive
carcinoma in the residual cervix of patients whose
conization revealed high-grade intraepithelial neoplasia
at the margin. The risk is greatest in women over 50 or
whose colposcopic evaluation is unsatisfactory.
The Status of the Margins
Margins are a predictor for recurrent disease regardless of
whether conization was performed. Eight major studies
were reported in the 1970s and 1980s that encompassed
3894 cones. In this group, there were 3066 with cleared
margins and an overall 2.9% rate of recurrence or persis-
tence. There were 828 cones (21.3%) with involved margins,
with a 22% rate of recurrence or persistence. In a review
of 20 articles, positive margins varied from 13% to 45%.
Recurrences with positive margins ranged from 10% to
69% with negative margin from 5% to 38%. Although
the presence of involved margins does not necessarily
indicate the need for immediate further action other than
careful observation in most cases, patients should be
counseled on increased risk for persistent or recurrent
disease.128
In summary, the assessment of surgical margins should
be attempted on all specimens sent for pathologic review.
Endocervical evaluation and margin status may predict
risk for recurrent or persistent disease. For the endocervical
evaluation, it is acceptable to use either an ECC or an
endobrush, although the latter has limited specificity when
employed immediately following excision.
Postexcision Follow-Up
Parameters that influence outcome following excisional
or ablative therapy include (1) size of lesion treated, (2)
presence or absence of a positive endocervical curetting
during or following the cone biopsy, (3) presence or absence
of positive ecto- or endocervical margins in excised speci-
mens, (4) post-therapy cytology, (5) HPV status post-therapy
and in some studies, and (6) the age of the patient.
Regarding recurrence risk the following should be noted:
• The percentage of patients with abnormal histologic
outcome that are preceded by an abnormal cytology.
Most, if not all, positive histologic outcomes are associ-
ated with abnormal cytology.129
• Likelihood of detecting HPV diminishes with time from
nearly 50% at 6 months to 1.1% at 24 months, and
the odds ratio for recurrence if HPV positive at 24
months is 26.130 One study showed that the follow-up
risk for CIN3 a cytologically negative, HPV negative
case was zero.87
• Most recurrences following an interval of normal cytol-
ogy are either infections by other HPVs or infections
by the same HPV but confined to the ectocervix. This
underscores the shift in recurrence location once the
SCJ is removed.86
• Causes of reported abnormalities in Pap smears following
cone biopsy include not only squamous cell abnormali-
Cervical Squamous Neoplasia 13
ties but also thermal artifacts following LEEP and
spurious glandular cell atypias because of sampling of
the lower uterine segment. The evidence indicates that,
for most studies, post-procedural cytology is a sensitive
test for recurrent disease but carries a small false-negative
rate. Specificity may vary depending on the experience
of the cytopathologist and variables (cautery artifact,
changes in anatomy) that alter the nature of the post-
procedure cytologic specimen.
In summary, when considering HPV testing as an adjunct
to the Pap smear, the following can be expected:
• The sensitivity and negative predictive value of HPV
testing is high and can be used either as an adjunct to
cytology or, more important, as a tool to exclude
nonspecific atypias developing postablation.
• HPV testing done prior to 6 months’ post-ablation is
not recommended unless the patient has a cytologic
abnormality.
• A negative HPV test at 1 year, combined with a negative
smear, carries a very high negative predictive value.
Diagnosis and Management of Invasive
Squamous Cell Carcinoma
Introduction
Since the late 1960s, pathologists have witnessed a dramatic
reduction in the number of cervical cancers and, most
significantly, the proportion that are advanced. The case
example of a cervical cancer with parametrial spread, nodal
involvement, and hydronephrosis is a rarity in the United
States, albeit more common in low-resource settings where
women are seldom screened. Currently fewer than 11,000
women/year develop carcinoma of the cervix, and practi-
tioners are noting a higher proportion of adenocarcinomas,
which are not infrequently seen in women in their third
and fourth decades.131 This group is discussed in Chapter
14. The majority of squamous carcinomas occur in women
who are between ages 40 and 55, with approximately 10%
younger than 30 years old. At least 50% are stage I when
diagnosed. Of stage I tumors, 10% to 15% will be less
than 5 mm in depth (stage IA). Survival is close to 100%
for stage IA and diminishes with invasion beyond 5 mm
and extension beyond the cervix (stage IIA) (Tables 13.8
and 13.9).132
Colposcopic, Cytologic, and Histologic Predictors
of Malignancy
Sensitivity and Specificity of the Papanicolaou Test
for Invasion
The clinician will either suspect the diagnosis of invasion
based on (1) symptomatology, (2) the cytologic report,
(3) colposcopic examination, or (4) discover the invasion
following pathologic examination. The biopsy will cor-
roborate a Pap diagnosis of invasive cancer in nearly 90%
of cases.133 In contrast, when the Pap is “suspicious” for
invasion or microinvasion, the predicted value drops to
22% and 17%, respectively.134 Sensitivity of the Pap for
microinvasion increases as a function of lesion depth,
ranging from 14% to 88% for lesions less than 1 mm,
and greater than 2 mm in depth.135 The cytologic features
of invasive cervical cancer is discussed in detail later in
347
 Diagnostic Gynecologic and Obstetric Pathology

Table 13.8  Staging of Cervical Squamous Carcinoma Table 13.9  Stage-Specific Frequency, Mean Age, and
(International Federation of Gynecology and Obstetrics) Outcome of Cervical Carcinoma

Stage Description Stage Percentage Mean Age 5-Year Survival (%)

Stage I Tumor Is Strictly Confined to Cervix IA1 4.4 44.5 99

IA Preclinical carcinomas of cervix diagnosed only by IA2 3.2 44.6 97

microscopy; all gross lesions even with superficial invasion
are stage IB cancers, invasion is limited to measured IB 39 48.6 80
stromal invasion with maximum depth of 5 mm and no
wider than 7 mm IIA 6.9 55.5 66

IA1 Stromal invasion no greater than 3 mm and no wider IIB 2.2 53.7 64
than 7 mma
IIIA 1.5 63.0 33
IA2 Maximum depth of invasion of stroma greater than 3 mm
and no greater than 5 mm taken from base of epithelium, IIIB 19.8 56.4 39
either surface or glandular, from which it originates;
horizontal invasion not more than 7 mm IVA 2.5 60.1 17

IB Clinical lesions confined to the cervix or preclinical lesions IVB 1.7 58.1 9
greater than stage IA From Eddy GL, Bundy BN, Creasman WT, et al: Treatment of (“bulky”) stage IB cervical
cancer with or without neoadjuvant vincristine and cisplatin prior to radical
IB1 Clinical lesion no longer than 4 cm in size hysterectomy and pelvic/para-aortic lymphadenectomy: a phase III trial of the
Gynecologic Oncology Group. Gynecol Oncol 106:362-369, 2007.
IB2 Clinical lesion greater than 4 cm in size

Stage II Extension Beyond Cervix but Not to Pelvic Wall;

Involves Vagina but Not the Lower Third

IIA Involves vagina, but not lower third; no obvious extension

to parametria

IIB Involves vagina, but not lower third; obvious parametrial

involvement

Stage III Extension to Pelvic Wall; on Rectal Examination, No

Cancer-Free Space Between Tumor and Pelvic Wall;
Involves Lower Third of Vagina

IIIA No extension to pelvic side wall

IIIB Extension to pelvic side wall

Stage IV Extension Beyond True Pelvis or Involvement of

Bladder or Rectal Mucosa

Bullous edema does not permit a case to be assigned to

stage IV
a
Definition of microinvasion by the Society of Gynecologic Oncologists (SGO) includes
these criteria plus absence of capillary-lymphatic space invasion.
Adapted from Pecorelli S: Revised FIGO staging for carcinoma of the vulva, cervix,
and endometrium. Int J Gynaecol Obstet 105(2):103-104, 2009.
the chapter. As a rule, approximately 1 in 1000, 650, and
150 ASCUS, LSIL, and HSIL Paps, respectively, will be
followed by a diagnosis of invasive squamous cell carci-
noma on biopsy.136
Tumor diathesis is traditionally associated with invasive
squamous cell carcinoma of the cervix but is not invariably
present (Fig. 13.39). Rushing and Cibas examined 28
smears from 19 patients with squamous carcinoma and
reported diathesis in 54%, with diathesis correlating with
depth of invasion. They concluded that it may not always
be possible on cervicovaginal smears to distinguish between
an intraepithelial lesion and a shallow invasive cancer.137
348
Fig. 13.39.   Tumor diathesis in a cervical cytology preparation.
Role of Human Papillomavirus Testing
Although HPV testing is not considered a front-line
diagnostic test for cancer per se, one recent study empha-
sized its value in low-resource settings. In this study, a
single HPV test proved to be the most effective at detecting
cervical cancers earlier and in a more treatable form than
visual inspection only and cytologic screening.138 Although
such results may not be translated to populations with
access to multiple lifetime Pap tests, they further reinforce
the potential advantages of HPV testing when the options
limit the number of tests.
Cytologic Alterations Most Commonly Associated With
“Missed” Invasive Carcinomas
The following changes are uncommonly associated with
cancer, but based on experience derived principally from
 Cervical Squamous Neoplasia 13

medical-legal consultation, the five major pitfalls in rec-
ognizing invasive squamous or glandular carcinomas and
their precursors include the misclassification (or under-
appreciation) of the following (Fig. 13.40):
• Keratinizing lesions: Abnormal keratinizing cells must
be approached with caution (see Fig. 13.40A), and the
diagnosis of LSIL to describe such lesions without some
qualification is not recommended.
• Immature squamous cells with a metaplastic-cell
phenotype (see Fig. 13.40B): Atypical immature squa-
mous cells with a metaplastic phenotype are among
the more difficult to identify and appreciate. With the
higher index of suspicion seen in current practice, the
overdiagnosis of innocuous immature metaplasia is also
likely, particularly on liquid-based preparations.
• HCGs of cells (see Fig. 13.40C): Invasive squamous
or adenocarcinomas may present with sheets of cells
with variable degrees of nuclear atypia. Typically, these
cell aggregates overlap and exhibit nuclear enlargement
and prominent nucleoli. They may be misinterpreted as
endometrial, lower uterine segment, and endocervical
cells. These are discussed in greater detail in Chapter 14.

A B C

D E
Fig. 13.40.  Cytologic findings associated with cancers or their precursors that may be missed or
underappreciated include abnormal keratinizing cells interpreted as low-grade squamous intraepithelial
lesion (LSIL) (A), small neoplastic cells confused with metaplasia (B), hyperchromatic clumped groups
of tumor cells interpreted as endometrial cells or reactive endocervical cells (C), and extremely rare,
koilocytosis (LSIL) (D) followed by invasive carcinoma (E).
349
 Diagnostic Gynecologic and Obstetric Pathology
• HSIL or carcinoma associated with “classic” koilocytosis
(rare): It is estimated that approximately 0.1% of LSIL
smears will be followed by a diagnosis of squamous
cell carcinoma. The authors have encountered two cases
of this type, one of which contained cells raising the
possibility of a higher-grade SIL in addition to LSIL
(see Fig. 13.40D and E).
• “Reactive appearing” but atypical endocervical cells:
Adenocarcinomas of the cervix may occasionally present
with small clusters of cells closely resembling reactive
changes.
Clinical Detection of Invasion
When a mass lesion is present, the diagnosis of invasion
is not difficult (Fig. 13.41A-C). Colposcopy will detect a
proportion of these lesions (see Fig. 13.41D and E).
However, the colposcopist can expect to miss a significant
proportion of early invasive squamous cell carcinomas
of the cervix. In one study, the sensitivity of colposcopy
for microinvasion was 50%, but specificity was 91%. In
one-third of cases, neither the colposcopic examination
nor the Pap smear identified invasion.139 Atypical vessels
were found in only one-third of cases in the study by
Liu et al.140
Percentage of High-Grade Squamous Intraepithelial
Lesions Associated With (Micro) Invasion
The proportion of biopsy-proven HSILs associated with
early invasion varies from less than 1% to 7%. In a recent
clinical trial of 125 women with documented HSIL who
were followed for 6 months, one (0.8%) was found to
have early invasion on cone biopsy.141 In a follow-up study,
we found no cancers in 300 women younger than 25 years
old with HSIL on biopsy.141a
Risk of Invasion Following Treatment for High-Grade
Squamous Intraepithelial Lesion
Soutter et al. observed more than 2000 women with more
than 44,000 woman-years of follow-up. A total of 33
developed invasive cancer: 14 microinvasive with a cumula-
tive rate of invasion 8 years after treatment of 5.8 per 1000
women and 85 per 100,000 woman-years.142 The risk of
developing cancer did not change throughout the follow-up
period, and the authors concluded that conservative
outpatient therapy reduced the risk of invasive cancer by
95% during the first 8 years after treatment. However, even
with careful, long-term follow-up, the risk of invasive
cervical cancer among these women is about fivefold the
general population of women. The authors recommended
continued follow-up for at least 10 years after conservative
treatment of CIN. Given the negative predictive value of
HPV testing, it is likely that the risk is less in cases docu-
mented as HPV negative.
Features of High-Grade Squamous Intraepithelial
Lesion Portending Stromal Invasion
In general, there is no method that predicts which HSIL
will progress to invasion. However, some authors have
350
identified features more commonly seen in HSILs associated
with invasive carcinoma. These include the following:
• Extensive involvement of surface epithelium and deep
endocervical crypts by expansile HSIL must be distin-
guished from a nested pattern of invasion.
• Luminal necrosis with keratin debris in the centers of
what appear to be crypts must also be carefully evaluated
to exclude nested pattern of invasion.
• Intraepithelial squamous maturation (Fig. 13.42A and
B) is not diagnostic but a worrisome finding. Other
features of concern include disorganized epithelial
growth in which the epithelium contains discrete
independent units of proliferating cells (see Fig. 13.42C
and D), papillary architecture (see Fig. 13.42E), and,
possibly, the presence of other forms of differentiation
in the form of conspicuous mucin production (see Fig.
13.42F).143 Tidbury et al. found that the extent of HSIL
was sevenfold higher in cases with invasion.144
• Unusual fibrous proliferations in the stroma should
also alert the pathologist to the possible presence of
invasion, although the same may be produced by biopsy
artifacts. Under certain circumstances, a diagnosis of
invasion may be suspected in the evaluation of an ECC
based on the previously described criteria.
Diagnosis of Invasion
Introduction
Before classifying a cervical tissue sample as invasive
carcinoma, the pathologist must manage four tasks, which
comprise (1) determining whether invasion is possibly
present, (2) excluding mimics, (3) applying the criteria
for superficially invasive (or microinvasive) carcinoma,
and (4) advising the clinician with the use of appropriate
reporting.
As mentioned earlier, abnormal differentiation, increased
epithelial thickness, loss of polarity, altered differentiation,
and mucin production may herald a greater risk of invasion.
The latter is often associated with adenocarcinoma in situ,
and not infrequently is associated with invasive carci-
noma.115,145 However, ultimately, the diagnosis rests on
criteria specific for stromal invasion.
How does one approach “borderline microinvasion”?
Although it is not an accepted category, Wilkinson and
Komorowski defined borderline microinvasion (less than
1 mm) and assessed its risk.146 The authors noted that
4.8% and 27% of in situ and microinvasive lesions were
reclassified as “borderline invasion.” They found no
metastases in the 29 cases they followed. The implication
is that a diagnosis of suspicious for, or diagnostic of, very
early stromal invasion (or that which is suspicious for
invasion) can be managed conservatively. Another term
likely applied to this form of invasion is budding invasion,
where altered differentiation is appreciated at the epithelial
stromal interface but no stromal infiltration is present.
Criteria for Invasive Squamous Cell Carcinoma
The most commonly used criteria for invasion include
the following:
• A desmoplastic response in the adjacent stroma
(Fig. 13.43A)
 Cervical Squamous Neoplasia 13

A B

E
Fig. 13.41.   Gross appearance of invasive squamous cell carcinoma (A) seen as a fungating mass at

the os in the opened cervix (B). C, A smaller carcinoma is situated at the squamocolumnar junction
(SCJ). Low (D) and higher power (E) colposcopic images of a squamous cell carcinoma. E, Note the
abnormal vessels. (B and E, Courtesy Dr. Quek Swee Chong.)

351
 Diagnostic Gynecologic and Obstetric Pathology

A B

C D

E F
Fig. 13.42.   Features that increase the risk of associated invasive carcinoma include aberrant differentiation

(A and B) with or without disorganized epithelial growth (C and D), papillary architecture (E), and
intraepithelial mucin production associated with stratified variants of adenocarcinoma in situ (F).

• Focal conspicuous maturation of the neoplastic epithe-
lium with prominent nucleal (see Fig. 13.43A and B)
• Blurring of or lack of a sharp contrast between epithelium
and stroma, often seen at lower magnification
• Loss of polarity of the nuclei at the epithelial-stromal
border with absence of the palisaded pattern charac-
teristic of CIN (see Fig. 13.43B)
Three additional features include:
• Scalloping of the margins at the epithelial-stromal
interface (see Fig. 13.43C): Scalloping refers to fine
352
irregularities, which are not typically seen with gland
(crypt) involvement or tangential sectioning through
gland involvement.
• The appearance of pseudocrypt involvement (see Fig.
13.43D and E): Pseudocrypt involvement is defined as
discrete circumscribed nests of invasive carcinoma,
usually with central necrosis, that may mimic crypt
involvement. In contrast to crypts, this form of invasive
carcinoma does not exhibit glandular epithelium, is
often composed of multiple circumscribed nests, often
 Cervical Squamous Neoplasia 13

C D

E
F
Fig. 13.43.   A and B, Diagnosis of invasion includes loss of polarization, maturation, and desmoplasia;

C, scalloped contours; D, pseudoglands with desmoplasia or, E, retraction artifacts; and complex interlacing
growth patterns (F, “epithelial duplication”).
353
 Diagnostic Gynecologic and Obstetric Pathology

contains central necrosis, and may display a loss of
polarity.
• Apparent “folding or duplication” of the neoplastic
epithelium (see Fig. 13.43F): Duplication of epithelium refers
to the presence of vascular structures within a sheet of
neoplastic epithelial cells, producing an image of incom-
pletely formed papillae. These features aid in recognizing
invasion in the presence of an intense inflammatory
response, which may obscure desmoplasia on the one
hand and blur the epithelial-stromal interface on the other.
Immunohistochemistry
Differential Diagnosis of Invasion
A previous review of 265 cases of presumed microinvasion
sent to the Gynecologic Oncology Group (GOG) deter-
mined that approximately one-third were overdiagnosed
intraepithelial lesions, underscoring the potential problems
in lesion interpretation.147 The most important mimics of
microinvasion include the following:
• Tangentially sectioned epithelium, benign or neoplastic
(Fig. 13.44A)
• Prior biopsy sites (see Fig. 13.44B)
• Inflammatory or reparative changes in CIN, including
pseudoepitheliomatous changes (see Fig. 13.44C)
• Obscuring of the epithelial-stromal interface by inflam-
mation or other artifacts (see Fig. 13.44D)
• Crypt (gland) involvement that is inflamed or tangentially
sectioned (see Fig. 13.44E and F): Crypt involvement
is characterized by preservation of epithelial polarity, a
smooth epithelial-stromal interface, and, in contrast to
the parameter of duplication, each nest of epithelium

A C

B D
Fig. 13.44.  Mimics of invasion include tangential section of metaplasia (A), displaced benign epithelium
from a biopsy artifact (B), and pseudoepitheliomatous hyperplasia in a squamous intraepithelial lesion
(SIL) (C, because of underlying submucosal leiomyoma). Disrupted benign mucosa with inflammation
(D), and extensive crypt involvement with inflammation (E). F, The latter is typically distinguished from
invasive carcinoma by the preservation of polarity and a sharply defined epithelial stromal interface.
G, Large aggregates of activated lymphoid cells in ill-defined germinal centers can mimic malignancy.
354

F G
Fig. 13.44, cont’d.
is discrete and separate from the adjacent one. Artifacts
are usually produced by prior biopsy, in which a stromal
response may be present. They should not be associated
with the other parameters of invasion.
• Cautery or crush artifact: Cautery or crush artifact should
be recognized and reported if it hinders diagnosis.
Inflammatory changes are responsible for the greatest
diagnostic difficulty, because these alterations may blur
the epithelial-stromal interface or, in combination with
prior trauma, be associated with small nests of epithe-
lium in the inflammatory cell infiltrates.
• Misinterpretation of cancer in the ECC, including
implantation site and floaters from other sites
The laboratory management of these findings is to obtain
levels to determine whether additional features of invasive
carcinoma are present and obtain consultation if there is a
question of invasion in a cone specimen. Factors influencing
Cervical Squamous Neoplasia 13
management include whether the areas in question are in
continuity with, or within 1 mm of, the surface epithelium;
are limited to one or two foci; are not associated with other
parameters of invasion, including capillary–lymphatic space
invasion (CLSI); and are associated with clear margins.
Intraepithelial lesions associated with underlying inflam-
mation, either from secondary infection or previous biopsy,
must be evaluated carefully to avoid the ovediagnosis of
invasion when the epithelial-stromal interface is disrupted
by the inflammatory process. Another mimic of invasion
is placental implantation site, which was discussed earlier.
Defining Superficially Invasive (Microinvasive)
Squamous Cell Carcinoma
In recent years, the proportion of invasive cervical carci-
noma diagnosed at an early stage (less than 5 mm in
355
 Diagnostic Gynecologic and Obstetric Pathology

• It is not clearly deeper than 3 mm in the original biopsy

Table 13.10  Follow-Up of Stage IA Cervical Cancer
and does not exhibit CLSI.
• The amount of tissue in the sample is small.
Positive
Stage Definition Nodes Recurrences Deaths (%)
Measurement of Invasion
1A1 <1 mm 0.07 0.38 0.07
Once the cone biopsy is performed, the measurement of
1 to 2.9 mm 1.9 1.5 0.5 depth of invasion should be made from the most superficial
epithelial-stromal interface of the adjacent intraepithelial
1A2 3 to 5 mm 7.8 4.5 2.4 process (Fig. 13.45A). This is not always possible if the
From Eddy GL, Bundy BN, Creasman WT, et al: Treatment of (“bulky”) stage IB cervical tissue is distorted or the epithelium is absent, in which
cancer with or without neoadjuvant vincristine and cisplatin prior to radical
hysterectomy and pelvic/para-aortic lymphadenectomy: a phase III trial of the
case the thickness of the tumor should be measured (see
Gynecologic Oncology Group. Gynecol Oncol 106:362-369, 2007. Fig. 13.45B and C). This is best accomplished using an
ocular micrometer or a method of measurement that makes
it possible to identify with certainty if the lesion has invaded
Table 13.11  Frequency of Capillary-Lymphatic Space to a depth of over 3 mm. If the microscope stage has a
Invasion, Nodal Involvement, and Recurrence Risk micrometer scale, the epithelial-stromal interface or top
of the lesion can be placed at the upper edge of the field.
Capillary-Lymphatic
Depth of Invasion Taking note of the scale, the stage can be moved until the
Space Invasion <1 mm 1 to 2.9 mm 3 to 5 mm top of the field reaches the lower limits of invasion.
The distance traveled can be determined by examining
Frequency 4.4% 16.4% 19.7% the scale (see Fig. 13.45D).
Recurrence risk Present 3.1% 15.7%
Parameters of Importance
Absent 0.6% 1.7%
The following issues require attention when considering
Nodal involvement Present 8.2% 7.5% microinvasion:
• Tumor type: This discussion is limited to squamous
Absent 0.8% 8.3%
carcinomas. However, certain subsets of squamous
From Lecuru F, Neji K, Robin F, et al: Microinvasive carcinoma of the cervix: rationale carcinoma, such as papillary squamous carcinomas,
for conservative treatment in early squamous cell carcinoma. Eur J Gynaecol Oncol
1:465-470, 1997.
may not be as easily evaluated without complete exci-
sion. Neuroendocrine carcinomas and adenocarcinomas
naturally will be evaluated using different criteria.
depth) has increased more than tenfold and currently is • Tumor dimension (depth and length): The risk of pelvic
approximately 21%. Staging systems for early invasive lymph node metastases increases significantly between
cervical cancer are designed to integrate biologic behavior 1 and 5 mm of invasion and is estimated as high as
and clinical management (Tables 13.10 and 13.11). 4.3% for lesions invading between 3.1 and 5 mm (see
Squamous carcinoma of the cervix was previously staged Table 13.10).148-151
under two systems endorsed by the Society of Gynecologic However, a diagnosis of microinvasion (as defined by
Oncologists (SGO) and International Federation of the therapeutic alternatives of conization or simple hys-
Gynecology and Obstetrics (FIGO), respectively. The terectomy) in the United States requires that the carcinoma
principal difference between the two systems was in the invade less than 3 mm into the stroma, based on recom-
staging of early invasion. The SGO-endorsed system defined mendations of the SGO. Burghardt et al. proposed that
stage IA as equal to or less than 3 mm in depth by 7 mm tumor volume be taken into account as a more precise
in length without CLSI. This cut-off distinguished cases predictor of recurrence and metastases. Lesions smaller
amenable to conservative (excision-only) therapy from than 420 mm rarely recur.152 A more simplified approach
those requiring lymph node dissection. The FIGO system places the cut-off at 7 mm in length.153
originally subdivided stage I into “minimal invasion” (less
than 1 mm) and invasion less than 5 mm in depth, making
Capillary-Lymphatic Space Invasion
no recommendation as to management. The two systems
have since come into near agreement, using the SGO The frequency of CLSI has varied widely but increases as
definition to identify stage IA squamous cell carcinoma a function of depth. Van Nagell et al. and Ostor, Rome,
of the cervix (see Table 13.8). and Quinn reported CLSI in 24% of superficially invasive
carcinomas based on Ulex europaeus agglutinin I (UEAI)
stains.151,154 They noted that six of 12 (50%) tumors with
When Cone Biopsy Should Be Considered
lymph node metastases were associated with CLSI, not-
If either superficial invasion or a growth pattern character- withstanding the fact that 19% of cases with negative lymph
izing invasion (confluent neoplastic growth or papillary nodes had CLSI. Similarly, 50% of invasive recurrences
carcinoma) is identified in a biopsy specimen, cone biopsy were associated with CLSI in the original tumor versus
is necessary in the following situations: 14% of patients with no recurrence. CLSI has been associ-
• The lesion does not appear grossly invasive clinically ated with an adverse prognosis in carcinomas exceeding
or colposcopically. 3 mm in depth in most, if not all, reports.155,156 The
356
 Cervical Squamous Neoplasia 13

A B

C
Fig. 13.45.  A, Views of different patterns of stromal invasion. Conventional infiltration is measured
from the highest epithelial-stromal interface, seen here as a cleavage plane where the epithelium has
lifted from the stroma. B, Invasive patterns mimicking gland involvement are best measured from the
surface. C, When the distinction of intraepithelial and invasive components cannot be made, a measure
of thickness is most appropriate. D, Microscope stage scale can be used to determine distance in millimeters
from one point in the slide to another, measuring the distance traveled across a single reference point
(microscopic field edge).

implication from these multiple studies is that the majority
of cases with CLSI do not present with histologically
positive lymph nodes, but CLSI is associated more com-
monly with an adverse outcome.
In a review, Benedet and Anderson computed a tenfold
increased risk (8.3% vs. 0.8%) of nodal metastases in stage
IA1 (less than 3 mm invasion) tumors with CLSI, conferring
a risk of metastases of over 8% and recurrence of 15%
(see Tables 13.10 and 13.11).157 Thus, there is sufficient
evidence of increased risk to warrant careful counseling
of patients whose tumors contain CLSI and serious con-
sideration of lymph node dissection, while recognizing
that more than 85% of stage IA1 tumors with CLSI will
not have nodal metastases. It is important to emphasize
that not all risk can be eliminated by lymph node dissec-
tion. One study found a relationship between CLSI and
extrapelvic recurrences, whereas another found that a worse
prognosis associated with CLSI was not influenced by
lymph node dissection. Nevertheless, because an appre-
ciable number of patients with positive pelvic lymph nodes
are salvaged, prudence dictates that the nodes be removed
or sampled if CLSI is unequivocal.
In practice, oncologists request that the presence of
CLSI be reported and usually opt for radical therapy if it
is seen in a lesion less than 3 mm in depth. For these
reasons, over- and under-interpretation of CLSI must be
avoided.
CLSI typically exhibits the following features: (1) rounded
nests of tumor cells, (2) enclosed within a sharply defined
space, (3) molding of the tumor nests to the vascular
space, and (4) an absence of a surrounding stromal
response (Fig. 13.46A and B).
Conditions Mimicking Vascular Space Invasion
• Retraction artifacts may produce confusion in the
interpretation of CLSI. To avoid this pitfall, it is best
to evaluate CLSI at the periphery of the lesion and to
avoid the diagnosis of CLSI in the proximity of desmo-
plasia (Figs. 13.46A and 13.47A and B).
357
 Diagnostic Gynecologic and Obstetric Pathology
A B
Fig. 13.46.  A, Capillary-lymphatic space invasion (CLSI) is best evaluated at the periphery of the
invasive tumor and should be devoid of tissue reaction (desmoplasia). B, CLSI is characterized typically
by nests of differentiated neoplastic epithelium within discrete spaces. Endothelial cells may or may not
be conspicuous.
• Neoplastic epithelium displaced into vascular spaces
during injection of anesthetic or during specimen
handling may also be confused with CLSI.158 This
condition is characterized by the following features:
• Prominent vascular dilatation in the area because
of the injection
• Intravascular neoplastic epithelium that closely
resembles CIN
• Variable contouring of the epithelium
• Evidence of trauma, including surface disruption
resulting from the needle tract (see Fig. 13.47C-E)
A diagnosis of CLSI should be made with caution
when invasion is not seen. Conversely, if the
characteristic features of CLSI are present, a
compulsive search for invasion should be made.
In discohesive tumors with abundant neoplastic
epithelium, transfer of tumor into larger vascular
spaces may occur by the process of “buttering,”
wherein sectioning spreads the cells into available
spaces. Such artifacts should be obvious by the
presence of loose aggregates elsewhere in the
specimen and the absence of the characteristic
rounded clusters of tumor cells.
• Other forms of pseudovascular space invasion include
menstrual endometrium within small vessels (see Fig.
13.47F). Recognition of this pitfall requires attention
to the nature of the cells within the vessels.
Reporting Superficially Invasive Squamous Carcinoma
We do not use the term “microinvasive” carcinoma, prefer-
ring to report such tumors as “superficially invasive
squamous cell carcinomas” and providing appropriate
358
information that will allow the clinician to come to a
conclusion regarding therapy. This is essentially the same
approach that is found in the World Health Organization
(WHO) monograph.159 The purpose of this strategy is
twofold. First, clinicians should not assume that a diagnosis
of microinvasion identifies an entity that is easily repro-
duced between pathologists. Determining which patients
are amenable to cone biopsy versus requiring lymph node
dissection is a subjective process, and clinicians should
be discouraged from presuming that a report stating
“microinvasion” does not require further review, to avoid
both overestimation and underestimation of invasion. As
a rule, all cases falling into the range of those defined as
microinvasion should prompt a dialogue between the
pathologist and clinician and, ideally, be reviewed by two
or more pathologists. When reviewing the biopsy, we report
the largest dimensions of the lesion to aid the clinician
in deciding the next step in management (i.e., cone biopsy
vs. radical hysterectomy), particularly if there is no visible
mass on clinical examination. In cone biopsies, the fol-
lowing should be reported:
• Depth
• Length of the entire lesion
• Whether length constitutes continuous tumor or is
composed of multiple small foci
• The presence or absence of CLSI
• The status of endocervical, ectocervical, and deep margins
and, if negative, distance (in millimeters) from invasive
tumor to these margins
• Intraepithelial disease and its relationship to the margins
• Glandular differentiation if present (criteria for “micro-
invasive adenocarcinoma” exist, but experience with
this entity is less extensive, and the oncologist must
 Cervical Squamous Neoplasia 13

A B C

D E F
Fig. 13.47.   Differential diagnosis of capillary–lymphatic space invasion (CLSI) includes retraction

artifacts (A and B), anesthetic needle tracts (C), and displaced neoplastic epithelium in vascular spaces
(D and E). This phenomenon is often accompanied by generalized submucosal vascular dilatation.
F, Menstrual endometrium may occasionally be present in vessels and may confuse the unwary.

always be made aware of glandular differentiation in
any invasive lesion)
Common Dilemmas and Their Management
• Multifocal lesions, none of which exceed the criteria
for microinvasion: These should be described in detail.
It is not uncommon to identify several small foci of
early invasion in multiple areas of different sections.
These foci may be technically greater than 7 mm in
aggregate distance from one another. This finding should
be reported in a narrative. In the authors’ experience,
it is unusual to encounter multiple foci, each of which
measures less than 3 mm by less than 7 mm in dimen-
sion. The latter circumstances would be more likely to
mandate lymph node dissection than the finding of
small foci of early stromal invasion.
• Invasion originating from an endocervical crypt: This
occasionally occurs and will elicit the favorite question
of many pathologists who manage this disease, which
359
 Diagnostic Gynecologic and Obstetric Pathology

is whether to measure the depth from the surface or
the crypt (Fig. 13.48). The most important distinction
to make when faced with this problem is to ensure that
the “crypts” are not actually cohesive nests of invasive
carcinoma. If they are, it is likely that the criteria for
• Suspicion of CLSI in a single space that is not confirmed
• Papillary lesions without stromal invasion (Fig. 13.49):
• CLSI in association with SIL only (as noted earlier):
Fig. 13.48.   Invasion from a crypt. When present as an isolated focus,
microinvasion have been exceeded. If not, the appropri-
ate practice is to measure the depth from the epithelial-
stromal interface of the crypt. Nevertheless, these findings
should be detailed in a narrative on the report and
taken into account when planning therapy.
on levels: The diagnosis of CLSI—and with it the almost
certain decision to perform lymph node dissection—
should be based on more than a single focus in a single
tissue section. If a single focus is seen or suspected,
multiple tissue sections should be reviewed. If one
suspicious focus cannot be confirmed on additional
sections, it should be reported in a narrative.
Depending on the degree to which the papillae are
well formed, the differential diagnosis includes a ver-
rucopapillary HSIL and a papillary squamous (or
squamo-transitional) carcinoma. If either diagnosis is
proposed, the report must specify that squamous cell
carcinoma cannot be excluded and that depth of invasion
cannot be assessed. Further diagnostic strategies (cone
biopsy) may be required if a mass lesion is not appreci-
ated before deciding whether a radical hysterectomy is
indicated.
When CLSI is present, two causes must be excluded,
both of which we have encountered in practice. The
first is artifactual introduction of neoplastic epithelium
into the vascular space, usually during the injection of
local anesthetic before the surgical procedure takes
place.158 The second is that an underlying invasive

the tumor can be measured from the epithelial-stromal interface of the carcinoma is present but has not been sampled. The
crypt. We also give the distance from the highest epithelial–stromal latter is confirmed by additional sectioning or further
interface. tissue biopsies.

A B C
Fig. 13.49.  A and B, Papillary squamo-transitional carcinoma may show minimal or no invasion in
limited samples. C, Confluence of epithelial growth with duplication of epithelium and multiple stromal
cores characterizes these tumors.
360

Management of Superficially Invasive Squamous
Cell Carcinoma (Stage IA)
Occult invasive cancers that are not visible to the naked
eye are staged as IA. Cone biopsy is an acceptable option
of definitive management if the lesion fulfills the criteria
for microinvasion and ample margins are identified. These
lesions constitute stage IA1. Studies of cone biopsy versus
hysterectomy have not shown a significant difference in
the risk of subsequent metastatic spread. Hysterectomy
(by any route) is the preferred approach for women who
do not desire to maintain their fertility. Cancers that do
not meet the criteria for microinvasion (i.e., extending
deeper than 3 mm into the cervical stroma, exceeding
7 mm in length, or showing unequivocal CLSI) are staged
as IA2. Modified radical hysterectomy and lymph node
dissection are the standards for these lesions. Cases with
multifocal disease that collectively span more than 7 mm,
or cohesive lesions with a blunt epithelial-stromal interface,
may be treated on a case-by-case basis.
Radical trachelectomy—combining removal of the cervix,
proximal parametrium, and a 1- to 2-cm vaginal margin
along with a pelvic lymph node dissection—has been
employed in recent years as a fertility-sparing alternative
to hysterectomy and pelvic lymph node dissection for the
management of stage IA2 and selected stage IB1 carcinomas.
The trachelectomy can be performed vaginally, abdominally,
or with laparoscopy. A cerclage suture is generally placed
at the time of the trachelectomy. A recent review of more
than 900 cases reports disease-free survival rates comparable
to those seen with radical hysterectomy.160 There have been
more than 300 pregnancies with 196 live births. Approxi-
mately 10% of the pregnancies have resulted in delivery
before 32 weeks.
A B
Fig. 13.50.   Three common patterns of squamous cell carcinoma of the cervix are A, large cell keratinizing
(well-differentiated); B, large cell nonkeratinizing (moderately differentiated); C, and small cell nonke-
ratinizing (poorly differentiated). Differentiation has minimal influence on prognosis for squamous
carcinoma.
Cervical Squamous Neoplasia 13
Pathology of Invasive Squamous Carcinoma
Grading
Grading of squamous cell carcinoma (Box 13.2) has rela-
tively little prognostic significance. There are three classically
described categories of differentiation. Predominantly
keratinizing tumors (grade 1) are mainly differentiated
with conspicuous keratin pearls (Fig. 13.50A). Large cell
nonkeratinizing carcinomas (grade 2) exhibit greater
nuclear pleomorphism, infiltrative borders, and inflam-
mation (see Fig. 13.50B), and small cell nonkeratinizing
carcinomas (grade 3) are characterized by sheets of smaller
nonkeratinized cells with high N/C ratio (see Fig. 13.50C).161
Four variants of large cell keratinizing and nonkeratiniz-
ing carcinomas are as follows:
• Lymphoepithelial-like carcinomas, which consist of
poorly defined aggregates of nonkeratinized tumors
BOX 13.2  Categories of Squamous Carcinoma
Squamous cell carcinoma
Large cell keratinizing (well-differentiated)
Large cell nonkeratinizing (moderately differentiated)
Small cell nonkeratinizing (poorly differentiated)
Lymphoepithelial-like carcinoma
Spindle cell (sarcomatoid) carcinoma
Verrucopapillary carcinomas
Papillary (squamo-transitional) carcinoma
Verrucous carcinoma (rare)a
Condylomatous carcinomaa
Basaloid carcinomasb
a
In young women, an extensive (giant) condyloma must be excluded.
b
May be associated with adenoid basal and adenoid cystic carcinomas, as well as
carcinosarcomas.
C
361
 Diagnostic Gynecologic and Obstetric Pathology

cells, often with indistinct cytoplasmic borders, inter-
mixed with abundant lymphoid cells, similar to their
morphologic counterparts in the pharynx: The term is
an adaptation of that used to define similar tumors of
the nasopharynx. The differential diagnosis includes
lymphoid hyperplasia and lymphoma, both of which
can be easily distinguished with stains for epithelial
cells (keratin, epithelial membrane antigen) or squamous
cells (p63) (Fig. 13.51A-C).162
• Spindle cell squamous cell carcinoma, also termed
“sarcomatoid squamous cell carcinoma,” has been
described in the vulva and cervix and consists of an
expansile tumor mass with a spindled cell component.163
The “sarcoma” is typically not differentiated, but tumors
with osteoclast giant cells have been reported.164 The
tumors frequently contain both squamous carcinoma
and spindle cell components, either separate or
subtly blending (Fig. 13.52A-C). Ultrastructural and

A B C
Fig. 13.51.   A and B, Lymphoepithelial-like carcinoma of the cervix exhibits an indistinct blending of

a monomorphic nonkeratinizing tumor with a prominent lymphoid infiltrate. C, Strong positivity for
p63 is consistent with a squamous origin.

A B
Fig. 13.52.  A, Spindle cell squamous carcinoma displaying the interface between epithelioid (center)
and spindled (sarcomatoid) elements. B, A stain for cytokeratin highlights the epithelial component.
362

immunohistochemical studies indicate that these tumors
are derived from squamous cell carcinoma and several
features will aid in the correct diagnosis of these tumors:
• True carcinosarcomas of the cervix almost always
arise in association with basaloid neoplasms. Thus,
if the pathologist encounters a spindle cell neoplasm
of the cervix not associated with a basaloid squamous
tumor, the differential diagnosis narrows to a pure
sarcoma versus a spindle cell carcinoma.
• If an epithelial component is appreciated, it will be
a typical large cell nonkeratinizing squamous cell
carcinoma.
• A spindle cell squamous carcinoma is also likely if
a precursor lesion (CIN) is also present. In some
cases, a transition from CIN or squamous carcinoma
(superficial) to spindle cell morphology (deep) is
present.
• Special stains for keratins will usually be positive
but may vary in intensity.
• Verrucopapillary neoplasms of the cervix that either are
malignant or can mimic malignancy are addressed as
a group for clarity (Table 13.12). They include the
following (Fig. 13.53A-F):
• Extensive (giant) condylomata are rare and are more
commonly reported in the anogenital mucosa,
particularly in men (see Chapter 10) (see Fig. 13.19).
The authors have seen two cases in the cervix that
were initially misinterpreted as verrucous carcinomas,
primarily because they were accompanied by extensive
hyperkeratosis and inflammation and lacked con-
spicuous koilocytotic atypia. Both were HPV-11
positive. One telltale finding is the extension of the
process into crypts with preservation of the overlying
columnar cells and lack of stromal replacement (see
Fig. 13.19).
• Well-differentiated squamous neoplasms with
conventional invasion constitute a unique subset
of tumors in which the papillary component fails
to fulfill the criteria for carcinoma but is associated
with frankly infiltrative squamous carcinoma (see Fig.
13.53A and B). The authors have seen rare examples
Table 13.12  Differential Diagnosis of Papillary Cervical Neoplasia
Tumor Differentiation
Condyloma (LSIL) Mature
Extensive (giant) condyloma Mature
Immature condyloma Immature squamous
Papillary squamotransitional carcinoma Immature squamous
Condylomatous carcinoma Mature squamous
Verrucous carcinoma Mature squamous
Papillary undifferentiated carcinoma None
LSIL, Low-grade squamous intraepithelial lesion.
Cervical Squamous Neoplasia 13
of this entity. In both, the invasive component was
either focal or unrecognized prior to hysterectomy.165
• Verrucous carcinomas are essentially unheard of in
the cervix, although we have encountered rare lesions
reminiscent of this entity (see Fig. 13.53C and D).
One review of reported cases reclassified most as
other forms of verrucopapillary neoplasia.166
• Conventional condylomatous lesions with invasion
and metastasis: We have encountered one case of
HPV-11 positive verruciform neoplasm of the cervix
that was indistinguishable from a large condyloma,
yet was associated with regional lymph node metas-
tases (see Fig. 13.53E and F).
• Papillary squamotransitional carcinomas of the
uterine cervix are characterized by filiform papillae
lined by neoplastic cells identical to high-grade CIN
and may have features resembling transitional cell
carcinoma of urothelial origin (see Fig. 13.49A-C).167
The term transitional is based principally on the light
microscopic appearance, inasmuch as special stains
for squamous (CK7) are typically positive and
transitional cell differentiation (CK20) is present in
less than 10% of cases. Because these tumors
are predominantly papillary, invasion may not be
confirmed and may require wedge biopsy or LEEP
cone. However, the majority (90%) will demonstrate
invasion with sufficient sampling.
• Condylomatous carcinomas consisting of well-
differentiated exophytic squamous cell carcinomas
with conspicuous superficial and basal cell atypias
are occasionally encountered. The most compelling
reason for subclassifying these tumors is to distinguish
them from verrucous carcinomas and condylomata.168
• Basaloid squamous carcinomas are extremely rare vari-
ants of cervical neoplasia that exhibit a mixture of
basaloid and variable mature squamous differentiation
(Fig. 13.54A-C). These tumors are technically squamous,
but some have been associated with adenoid basal
carcinomas and may actually arise from these tumors
early in their evolution. They may also be associated
with a sarcomatous element.
Koilocytosis Basal Atypia Infiltration
Yes No None
Variable No None
Minimal No None
No Yes Variable
Variable Yes Present
No Minimal Blunt
No Yes Present
363
 Diagnostic Gynecologic and Obstetric Pathology

A B

C D

E F
Fig. 13.53.   Verrucopapillary neoplasia. In addition to occasional large condylomata (see Fig. 13.19)

and papillary squamous carcinomas (see Fig. 13.49), there are other, even rarer lesions that might be
encountered. A and B, A lesion resembling a condyloma that abruptly transitions to an invasive squamous
carcinoma. C and D, More rare lesions that resemble in part a verrucous carcinoma. E, Rarely, a lesion
indistinguishable from a condyloma (upper and upper right inset) merges with a less well-differentiated
component (lower and lower left inset). F, Invasion was also demonstrated. This picture is rarely encountered
and can be associated with “low-risk” human papillomaviruses (HPVs).

364
 Cervical Squamous Neoplasia 13

A B

C
Fig. 13.54.  Carcinomas with basaloid phenotype may present as solid (A) or interlacing (B) cordlike
growth patterns. C, Strong staining for p63 confirms the basal (versus columnar) pattern of differentiation.

Reporting Squamous Carcinomas

Significance of Columnar Cell Differentiation
A significant proportion of cervical squamous carcinomas
are associated with columnar cell differentiation. The
prognostic significance of columnar differentiation is not
clear. In one study, 27% of randomly selected squamous
carcinomas contained some degree of mucin positivity.
Approximately 5% contained sufficient mucin to warrant
reclassification as adenosquamous carcinomas, suggesting
that mucin stains may in some cases aid in classification.169
In a second study, 87 stage I cervical carcinomas treated
by radical hysterectomy were studied. A total of 39% were
mucin positive, and this group (and pure adenocarcinomas)
was significantly associated with a higher risk of lymph
node metastases.170 Markers used to distinguish squamous
carcinomas from other tumors, including neuroendocrine
carcinomas, are discussed in Chapter 15.
Histologic reporting should include the following:
• Grade (well, moderately, or poorly differentiated)
• Cell type
• Depth of invasion or thickness
• Extent of tumor: The extent of invasion into extra-cervical
tissues and metastases to both pelvic and extrapelvic
organs should be recorded.
• Angiolymphatic vascular space invasion: The presence
of tumor within blood vessels or lymphatic vessels
should be noted and an attempt made to distinguish,
when possible, between them.
• Status of lymph nodes: The presence or absence of
metastases in each submitted group of lymph nodes
should be reported, recording the total number of
involved lymph nodes in relation to the total number
of lymph nodes identified.
365
 Diagnostic Gynecologic and Obstetric Pathology
• Status of resection margins: The adequacy of local
excision should be assessed by careful examination of
resection margins, the latter preferably marked by the
use of ink; the distance from the deepest point of stromal
invasion to the closest (inked) margin of resection may
be noted in the report.
Treatment and Outcome of
Squamous Carcinoma
Clinical Factors Influencing Outcome/Presentation
Presenting Signs/Symptoms
Pretorius et al. evaluated a cohort of 81 women with cervical
cancer and correlated presentation with outcome. Abnormal
vaginal bleeding and an abnormal Pap smear were the
dominant presenting findings (56% and 28%). Other
symptoms, such as pain and discharge, were seen in less
than 10%. An abnormal Pap smear was associated with
stage I disease and a significantly longer disease-free survival
(96%) than vaginal bleeding (51%). Both exceeded the
disease-free survival of those presenting with pain (29%).
Thus, early detection (by cytology) is associated with a
significantly higher disease-free survival and significantly
smaller tumor volume.171
Age of Presentation
Patients younger than 35 years old constitute slightly more
than 10% of women with cervical cancer and a disproportion-
ate number of those who have previously been screened.
Whether the under-35 age group is at greater risk of an
adverse outcome is doubtful. Jennings et al. performed a
retrospective cohort study comparing women younger and
older than 35 years old.172 They found no significant differ-
ence in the incidence of nonsquamous tumors, tumor grade,
lymph node involvement, HPV status, tumor recurrence, or
survival between the two groups. Young patients appeared
to enter the study at significantly earlier stages of the disease,
and a greater proportion of them underwent surgical treat-
ment.172 Yang et al. studied stage IB to IIA cervical cancers
among women 35 years old or younger and older and
reported a similar overall survival (71.2% vs. 72.4%) for
both groups. Nonsquamous carcinomas, including adeno-
carcinoma and small cell carcinoma, were both associated
with HPV-18 and the younger patients and conferred a slightly
higher but not significant risk of recurrence/persistence;
however, these differences were not significant, and 71% of
the recurrences were squamous cell carcinomas.173
Early studies of HPV prevalence in cervical cancer sug-
gested the existence of an HPV-negative older population,
possibly with a worse prognosis. Notwithstanding occa-
sional tumors in older women, such as minimal deviation
adenocarcinoma and verrucous carcinoma, that may not
be associated with HPV, a relationship between age and
HPV prevalence has not been substantiated in cervical
cancer. Baay et al. found no statistically significant differ-
ence in either the prevalence of HPV DNA or distribution
of genotypes between women with cervical cancer who
were younger or older than 65 years old.174
Presentation During Pregnancy
Carcinoma of the cervix during pregnancy is rare and is
diagnosed in approximately 1 per 3000 to 10,000 pregnant
366
patients.175,176 Conversely, approximately 3% of all cancer
patients are pregnant at the time of diagnosis. The two
important clinical issues are (1) influence of pregnancy
on outcome and (2) the risk of delaying delivery until
fetal maturity permits viability and the potential negative
impact of cone biopsy on the pregnancy.
Influence of Pregnancy on Outcome
Several studies of cervical cancer during pregnancy noted
no significant worsening of outcome.175,177,178 Adverse
outcome was directly related to tumor extent.
Safety of Delays in Treatment
In general, management of pregnant patients with cervical
cancer is as follows:
• Patients under gestational age of 20 weeks undergo
immediate surgery or irradiation with fetal loss. In some
patients with advanced disease, hysterotomy is required
to evacuate the pregnancy.
• Patients at gestational age of 20 weeks or older with
low-stage disease may be treated with observation of
up to 4 months.
• Conization can be performed safely for cases of early
(microinvasive) carcinoma. The safety of longer follow-
up intervals is unclear based on relatively few data.
Sorosky et al. followed seven stage IB pregnant patients
who desired pregnancy retention from 21 to 207 days
(median 109 days), with no adverse outcomes and no
apparent worsening of clinical stage.179
Inasmuch as chemoradiation is now being used to
manage women with more advanced cervical cancer, this
approach has been successfully used in selected women
in an effort to preserve the fetus and in small series without
adverse effect.180,181
Viral Factors and Outcome
HPV-16 predominates in squamous neoplasia in contrast
to HPV-18, which is seen more frequently in glandular
and neuroendocrine neoplasms. The role of HPV type as
an independent prognostic indicator has been addressed
in several studies. Many, but not all, indicate a worse
outcome for patients whose tumors harbor HPV-16 or
-18. Lombard et al. studied 297 patients for which HPV
typing was available (83%), with a median follow-up of
38 months.182 Although they reported no significant
relationship between virologic data and tumor stage/node
status, the 5-year disease-free survival rate was 100% for
patients with intermediate-risk HPV-associated tumors,
58% for patients with HPV-16–positive tumors, and 38%
for patients with HPV-18–positive tumors (p = 0.02). In
multivariate analysis, the RR of death conferred by HPV-18
was 2.4 times that of HPV-16, and it was 4.4 times that
for patients with a viral type different from HPV-16/18.182
Schwartz et al. similarly found the risk of tumor-related
mortality to be 2.2-fold higher in HPV-18– versus HPV-16–
positive tumors with the associations strongest for those
with FIGO stage IB/IIA disease. The HPV-18 associations
were strongest for patients with FIGO stage IB or IIA
disease.183 The increased risk was also seen in the subset
of patients with squamous carcinomas, with HPV-18
conferring increased risk, particularly in earlier-stage disease.
Lai et al. noted a significantly worse outcome for

HPV-18–positive tumors.184 Other studies have not found
a relationship between these HPV types and poor
prognosis.185,186
Management of Squamous Cell Carcinoma
Improvements in Prognosis Since the Late 1970s
Covens et al. summarized their experience in a large practice
and noted a consistent reduction in comorbidity (e.g.,
blood loss, length of stay, transfusion, infections) associated
with cervical cancer therapy over a 16-year period.187
However, parameters linked to early detection and prog-
nosis (age, tumor size, CLSI, and pelvic lymph node
involvement) did not change. They also noted a significant
increase in the proportion of adenocarcinomas (28%) and
a decrease in the proportion of grade 3 tumors (28%).
They concluded that most of the progress made was in
the realm of operative management than survival.185
Standard Treatment Options
Patients with invasive cervical cancer are staged clinically
based on a FIGO system that dates back to the 1930s.188
The system allows comparisons to be made between
patients treated primarily by surgery and those treated
primarily with radiation therapy. It does not allow the
stage to be changed by information obtained from a surgical
procedure. It also prohibits the inclusion of information
from “high-tech” imaging studies such as computed
tomography (CT), magnetic resonance imaging (MRI), or
positron emission tomography (PET) scans. Because
patients will be treated based on information not included
in assigning a clinical stage, in practice treatment will be
much more heterogenous than described here.
• Stage IA1: Management is detailed in the preceding
discussion of microinvasion.
• Stage IA2: Standard treatment would be a modified
radical hysterectomy with lymphadenectomy or radiation
therapy. Radical trachelectomy is an option for patients
wishing fertility preservation.
• Stage IB: Both surgery and radiation therapy can be
utilized for the management of stage IB1 cervical cancer
with similar-appearing results. However, significant
selection bias exists in determining who is selected for
surgery or radiation therapy.189 Radical hysterectomy is
the preferred option for smaller tumors and carries a
nearly 100% disease-specific survival rate for tumors
under 2 cm.190 Because of controversy regarding the
appropriate management of early-stage disease, Landoni
et al. performed a randomized study of radical surgery
versus radiotherapy for stage IB to IIA cervical cancer.191
These authors found no difference in overall or disease-
free survival. However, 46 of 55 (84%) patients with
bulky tumors in the surgery group received adjuvant
radiation for additional risk factors.
It has long been recognized that, among tumors limited
to the cervix, tumor size is predictive of nodal involvement
and survival.192 Although opinion over the appropriate
treatment has varied widely, the designation by FIGO of
stages IB1 and IB2 in 1994 established criteria differentiat-
ing the clinical management of smaller from larger gross
cervical tumors limited to the cervix. Finan et al.,
Cervical Squamous Neoplasia 13
retrospectively applying the FIGO 1994 definition, reported
stage IB2 cervical cancer patients had a significantly higher
incidence of nodal metastasis (21% vs. 44%) and poorer
survival (73% vs. 90%) following radical hysterectomy
than patients with stage IB1, despite the more frequent
use of postoperative radiation therapy (38% vs. 72%).193
Similarly, Trattner et al. found that stage IB1 patients had
an overall survival of 90% compared with the 40% 5-year
survival rate for stage IB2 patients.194
Recently, some investigators have questioned the need
for resection of the parametrium with lesions of less than
2 cm size (stages IA2 and IB1). They have proposed pelvic
lymphadenectomy combined with conization or simple
trachelectomy for patients who wish to maintain their fertil-
ity and pelvic lymphadenectomy with simple hysterectomy
for patients who have completed childbearing.195
There is controversy about the best approach to a patient
with a stage IB2 cervical cancer. Often these are endophytic
tumors, and patients are described as having a barrel-shaped
cervix. If these patients undergo primary surgery, a large
percentage will require adjuvant radiation or chemoradia-
tion. High-risk patients are those who have positive lymph
nodes, involvement of the parametrium, or involvement
of a surgical margin.196 All of these patients will be treated
with chemoradiation. An intermediate risk group has also
been defined by the GOG based on a scoring system that
incorporates clinical lesion size, depth of stromal invasion,
and involvement of the capillary-lymphatic space.197 For
these intermediate-risk patients, postoperative radiation
lowers the pelvic failure rate but has not been shown to
have a statistically significant impact on overall survival.198
Chemoradiation is now being studied in a randomized
trial for this intermediate-risk group.
Primary chemoradiation is also an option for stage IB2
tumors. The survival is roughly comparable to that obtained
with radical hysterectomy followed by adjuvant irradiation
or chemoradiation. The complication rate is thought to
be less for patients who receive primary radiation therapy
without hysterectomy. For patients with a bulky stage IB
tumor, simple hysterectomy was advocated following
completion of the radiation, but a GOG trial showed it
did not improve survival.199 Neoadjuvant chemotherapy
followed by radical hysterectomy and selective postoperative
radiation was advocated for a time. A recent GOG trial
showed this approach did not improve survival over that
obtained with radiation therapy alone.200
Stage IIA
For tumors that extend to the vagina but are limited to
the upper two-thirds, without involvement of the para-
metria, both radical hysterectomy and radiation therapy
have been utilized. Radical surgery would be suggested
for a younger patient if an adequate margin can be obtained
and adjuvant radiation can be avoided. However, if radia-
tion is likely to be required, primary radiation alone with
both external and intracavitary is usually preferable.
Stage IIB
For tumors that extend into the parametria (stage IIB),
the standard treatment in the United States has been
radiation therapy. In contrast, many European and Japanese
gynecologic oncologists have preferred radical hysterectomy
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 Diagnostic Gynecologic and Obstetric Pathology

and lymphadenectomy followed by adjuvant radiation
therapy. More recently, the introduction of chemotherapy
into a multimodality treatment for localized cervical cancer
has been extensively studied. Treatment schemas have
utilized chemotherapy administered before radical surgery
or radiation and concurrently with radiation. Because tumor
size is an important predictor of response to radiation
therapy and eventual survival, the use of chemotherapy to
reduce tumor size before the onset of definitive radiation
therapy is attractive. However, despite significant responses
to neoadjuvant chemotherapy, randomized trials have failed
to demonstrate improvement in survival, possibly because
of the development of crossresistance or tumor repopulation.
In contrast, the concurrent administration of cisplatin-based
chemotherapy has resulted in reproducible benefit in
randomized trials of cervical cancer patients with a variety
of stages and indications for radiation therapy.201-205 These
trials demonstrated improvements in disease-free and overall
survival of 30% to 50%, respectively, with concurrent
chemotherapy. Although the chemotherapy regimens varied,
the unifying theme was that all were cisplatin based. Based
on the favorable results of five large randomized trials in
cervical cancer, the National Cancer Institute issued a clinical
announcement advocating the concurrent use of cisplatin-
based chemotherapy with radiation for cervical cancer
patients who required radiation therapy.
Neoadjuvant chemotherapy has been studied for patients
who have locally advanced disease and are not thought
to be candidates for primary surgery. Various combina-
tions of chemotherapy agents have been studied.206-208
In some protocols, patients who responded to chemo-
therapy then had a radical hysterectomy, and in other
protocols those patients received a standard course of
radiation therapy. A Cochran review of randomized trials
suggested a benefit to neoadjuvant chemotherapy when
compared with standard radiation therapy.209 However,
neoadjuvant chemotherapy has not been compared with the
now-accepted regimens of concurrent chemotherapy and
radiation.
Recurrent cervical cancer represents a particularly difficult
problem, with few long-term survivors. The majority of
patients with recurrent disease present initially with locally
advanced disease and, as demonstrated in recent random-
ized trials, their disease-free and overall survival curves
are almost identical. For patients who have a localized
central recurrence following hysterectomy, radiation therapy
can be utilized. More commonly, localized recurrences
may follow radiation, and radical surgery (usually exentera-
tion) is required, with survival rates of 25% to 50%,
depending on patient selection criteria. Recent surgical
advances, including continent urinary diversion, anal
preservation, and vaginal reconstruction, can significantly
improve the patient’s quality of life. Patients with metastatic
disease who receive chemotherapy generally fare poorly,
with median survivals of 6 to 8 months. The addition of
the antiangiogenic agent bevacizumab to multi-agent
chemotherapy has been shown to increase survival in
patients with metastatic and recurrent cervical cancer.210
Prevention
Vaccines
Prophylactic HPV vaccines derived from viral-like particles
have been available for over 10 years and those targeting
HPV-16 and HPV-18 have been estimated to reduce the
risk of cervical cancer by 70% in a population of preme-
narchal women (Table 13.13; Fig. 13.55). The new non-
avalent vaccine targets nine types and is estimated to reduce
the rate of cervical cancer by 90% in an optimally vaccinated
population.211 Future challenges will entail recalibrating
the frequency with which cytologic screening will need
to be performed in the vaccinated population.212 A perpetual

Stage IIIA
Tumors with involvement of the lower third of the vagina
in patients who do not have extension to the pelvic side
wall are relatively rare. Concurrent chemotherapy and
radiation therapy would be appropriate for most of these
patients.

Stage IIIB
These patients have fixation to one or both pelvic side
walls or have obstruction of a ureter. Concurrent chemo-
therapy and radiation therapy is the accepted treatment.

Stage IVA
These patients have involvement of the bladder or rectum
without evidence of distant metastasis. A few of these
patients are candidates for pelvic exenteration, but most
will have pelvic side wall involvement and are treated with
concurrent chemotherapy and radiation therapy.
Fig. 13.55.   Viral-like particles similar to those currently used in vaccine
Stage IVB trials. (Viral-like particles produced by the laboratory of Robert Rose,
These patients present with metastatic disease and are usually University of Rochester, Rochester, NY. The micrograph is courtesy of
treated for palliation only. Treatment is individualized. Linda Stannard, University of Cape Town, Cape Town, South Africa.)
368
 Cervical Squamous Neoplasia 13

Table 13.13  Outcome of Vaccination for Human Papillomavirus

End Point Vaccine Population Vaccine Efficacy (%) Reference

Persistent infection HPV-16 Unex 100.0 11

Transient infection HPV-16 Unex 91.2 11

HPV-16 + CIN HPV-16 Unex 100.0 11

HPV-16/18 + CIN2 HPV-16/18 Unex 92.9 to 98.1 331

All CIN2 HPV-16/18 Ex 30.4 331

All CIN2 HPV-16/18 Unex 70.2 331

Other high-risk HPV + CIN2 HPV-16/18 Unex 54.0 331

All CIN3 HPV-16/18 Ex 33.4 331

All CIN3 HPV-16/18 Unex 87.0 331

CIN, Cervical intraepithelial neoplasia; CIN2, cervical intraepithelial neoplasia grade 2; Ex, exposed to HPV; HPV, human papillomavirus; Unex, unexposed to HPV.

epithelium, which is 10 to 20 times less vulnerable to

Fig. 13.56.  A new squamocolumnar junction (SCJ) following excision.
There is no evidence of metaplasia. It is postulated that following excision
of the original SCJ, the unique SCJ cells are not regenerated, and this is
one reason for the diminished risk of squamous cell carcinoma.
issue that must be addressed is maximizing the cost-
effectiveness of HPV vaccination in the societies that are
most vulnerable to cervical cancer.213 What can be antici-
pated, however, is a continued reduction in the incidence
and death rates for cervical cancer.
Targeting the Squamocolumnar Junction
The SCJ remains a largely unexplored primary target for
cervical cancer prevention, despite its tantalizing association
with the origins of cervical cancer.3 It is clear that removal
of the SCJ by cone biopsy or LEEP alters both subsequent
cervical cancer risk and the morphology of “late recur-
rences,” lesions that emerge after a period of normal cervical
cytology (Fig. 13.56). The theoretical basis for this would
be that removal of the most vulnerable cells brings the
risk of new HSILs closer to that expected for vaginal
malignancy. Several studies, each offering a different vantage
point, suggest that a prophylactic procedure that removed
the cells in or near the SCJ would significantly reduce the
risk of subsequent cervical cancer.
• Studies employing cautery to the cervix have reported sig-
nificant reductions in subsequent cervical carcinoma.214,215
• One study found that cryotherapy to the cervix reduced
the rate of subsequent HPV positivity to 50% of
untreated patients.216
• A study of cervical pathology and HPV status following
cone biopsy showed that delayed recurrences (presum-
ably signifying new vs. persistent untreated lesions)
were invariably on the ectocervix and low grade, with
frequent regressions. This implies that re-infections of
the ectocervical squamous epithelium by the same or
a different HPV type are far less likely to manifest as
HSIL.86
• We have found that SCJ-negative LSILs confer a very
low risk of subsequent HSIL.91
The aformentioned reports do not confirm with absolute
certainty that prophylactic cryotherapy of the cervix would
sharply reduce cancer risk, but the prospect that HPV
infection rates would diminish is an intriguing one. It
begs the question of whether removing the SCJ cells from
an HPV-positive/cytologically-negative woman would
reduce the likelihood of HPV detection in follow-up
and—by association—the risk of cervical neoplasia. Studies
of “see and treat” where acetowhite lesions of the cervix
are treated by ablation have shown a significant reduction
in CIN2-3 outcome.217,218 Studies that have recently identi-
fied morphologically latent HPV within SCJ cells have
further supported this concept.219 In fact a study of “screen
and treat” HPV-positive women were managed in three
groups: (1) cryotherapy, (2) cryotherapy if acetowhite
epithelium was seen, and (3) no therapy for 6 months.
Outcome CIN2+ was observed in 1.5%, 3.8%, and 5.6%,
respectively, underscoring the value of cryotherapy when
no visible lesion was observed.220 Similar albeit slightly
369
 Diagnostic Gynecologic and Obstetric Pathology
Table 13.14  Outcome Risk of Cervical Neoplasia Following Prophylactic Ablation of the Squamocolumnar Junction
Reference Population Group
214 General All
215 General All
216 South Africa HIV−/HPV−
221 Sourth Africa HPV+
a
Some differences noted between cases and controls in terms of socioeconomic status, age, and screening suggesting confounding variables.
CIN2, Cervical intraepithelial neoplasia grade 2; HIV, human immunodeficiency virus; HPV, human papillomavirus; SCC, squamous cell carcinoma.
less reductions were shown in HIV-infected women.221
These studies are summarized in Table 13.14. What should
be clear from these studies is that strategies that target the
source of cervical cancers have considerable promise and
in some settings could offer greater cost effectiveness than
complex screening guidelines.222
KEY POINTS
• The squamocolumnar junction (SCJ) has a unique
morphology and immunophenotype, emblematic of
cells capable of multi-potential differentiation, and the
SCJ immunophenotype is reproduced in a high
percentage of high-grade squamous intraepithelial
lesions (HSILs).
• The diagnosis of cervical intraepithelial neoplasia grade
2 (CIN2) is poorly reproduced across observers and p16
immunostaining, like high-risk human papillomaviruses
(HPVs), and has a broad range of expression across both
low-grade squamous intraepithelial lesions (LSILs) and
HSILs. Moreover p16 does not reliably predict an HSIL
outcome in LSILs. It has the most value (like HPV
testing) when it is negative.
• Temporal histologic “progression” from CIN1 to CIN2
or CIN3, although a time-honored concept, must be
viewed critically, because it can be falsely implied by
separate sequential or concurrent viral infections,
sampling errors, and histologic misclassification of the
index and outcome biopsy.
• Lesions falling into the gray zone between LSIL and
HSIL (CIN1-2) are lesions of indeterminate (or
intermediate) grade. If the pathologist is uncertain, this
should be communicated to the clinician.
• Always consider an extensive (giant) condyloma when
faced with a large, well-differentiated verrucous cervical
lesion in a young woman.
• A formal diagnosis of “microinvasive” squamous
carcinomas is best replaced with the diagnosis of
“superficially invasive” squamous carcinoma, with
appropriate information provided to facilitate
management.
• Increasing the stringency of the criteria (in terms of
interobserver agreement, association with high-grade,
cytology, etc.) for defining CIN2 is associated with a
370
Method Outcome Measure Change in Risk Versus Controls
Cautery SCC 6-fold reductiona
Cautery SCC 54-fold reduction a
Cryotherapy HPV+ 55% reduction
Cryotherapy CIN2+ 70% reduction
progressively higher index of associated HPV-16. This is
reflected indirectly in the high efficacy rates for all CIN2
and CIN3 in recent vaccine studies and suggests the
vaccines will have a major impact on clinically
significant CIN2 and CIN3.
• There is evidence that pre-emptive ablation of the SCJ in
women who are HPV positive will reduce their risk of an
HSIL or cancer outcome.
Please see the Appendix for suggested ICD-10 codes.
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