An approach to post-radical trachelectomy vaginal-isthmus cytology

Radical trachelectomy (RT) is the surgical amputation of the uterine cervix with paracervical lymphadenectomy, performed in reproductive age women to treat invasive squamous-cell carcinoma or endocervical adenocarcinoma while preserving the uterine corpus for potential child bearing. Post-RT patient monitoring includes isthmic-vaginal cytology. This study reviews our experience with liquid based preparation of post-RT cytology samples. Fifty-four post-RT vaginal-isthmic cytology specimens were reviewed from nine patients, seven with adenocarcinoma, and two with squamous-cell carcinoma. Five patients had normal (NILM) or normal with reactive changes on all cytology samples. Two patients had isolated squamous abnormalities (atypical squamous-cells of uncertain significance (ASC-US) and low-grade squamous intraepithelial lesion (LSIL)); both follow-up biopsies were negative. Two patients had repeatedly abnormal specimens interpreted as atypical glandular cells (AGC), one of whom also had a concurrent ASC-US. Only one sample was tested for high risk human papilloma virus (hrHPV), with negative results. All patients with abnormal cytology went on to have biopsies which were interpreted as benign. The cytology specimens most often interpreted as AGC contained many groups of hyperchromatic crowded glandular cells and/or stromal cells derived from direct sampling of the lower uterine segment. The crowding often limits visualization of all the cells in a group, plus sampled endometrium may harbor mitoses, adding to the atypical appearance. Cytologists should become familiar with the spectrum of changes in the post-RT cytology. Testing for hrHPV should be considered for use in the management of abnormal cytology results. Post RT cytology should be compared with presurgical cytology since one would anticipate similarities in post-RT true positive cases. In particular, a primary diagnosis of adenocarcinoma makes differentiating benign reactive glandular cells from recurrence a critical issue.