SARS-CoV-2 and COVID-19 has dominated the public health headlines for more than 12 months, and yet, there is a shadow story of viruses and vaccines, one in which global inequities are writ large.
One woman dies of cervical cancer every two minutes and nine in 10 of those deaths occur in low-and-middle income countries. Cervical cancer is a preventable disease and curable if detected early and adequately treated.
We received in the laboratory both a cervical screening test and an endometrial curetting sample from a 37-year-old woman with the clinical history stating “Menorrhagia”.
The cervical screening test (CST) underwent routine HPV testing for HPV 16, 18 and HPV “other”. As none of these were detected, the result of the CST for this patient was reported as HPV negative.
The concurrent endometrial sample was submitted for routine histological processing and the H&E-stained section was reviewed by the reporting pathologist. It showed proliferative endometrium with evidence of breakdown.
However, in addition to endometrial tissue, a few small strips of atypical squamous epithelium and admixed inflamed endocervical mucosa were seen (Figure 1). Further assessment utilising p16 immunohistochemistry was performed and the atypical squamous epithelium showed strong diffuse p16 expression (Figure 2), in keeping with a diagnosis of high-grade squamous intraepithelial lesion (HSIL, CIN 3).
Correlation between the endometrial sample and the CST showed a discrepancy, given the CST HPV negative result. So, a reflex liquid-based cytology sample was prepared from the CST sample. The cytology showed a single group of atypical cells with HSIL features along with background low-grade squamous intraepithelial changes (Figure 3) and the CST result was amended to HSIL with a recommendation for colposcopic evaluation.
This case highlights the importance of thorough evaluation and correlation between all samples submitted for a particular patient. The careful evaluation of the endometrial sample and the recognition of the small amount of admixed abnormal cervical tissue was crucial for the final diagnosis.
It was also essential to keep an open mind that, despite the negative CST, this abnormal tissue may reflect a true high-grade cervical pathology. In this case, the pathologist was able to go back and reassess the CST sample via cytology to show concordance between the two specimens.
The World Health Organization has recently resolved to adopt a global strategy to eliminate cervical cancer, proposing a threshold of 4 per 100,000 women-years for elimination as a public health problem. Provided vaccination and screening coverage are maintained at their current rate, Australia is on track to becoming the first country in the world to see cervical cancer rates drop below the elimination threshold, estimated to occur by 2035.
We, in Australia, must work to build on the successes of our screening program and further reduce cervical cancer. Strong partnership between clinicians and pathologists will remain a key factor in achieving this goal.
Key messages
- Thorough evaluation and correlation between all samples is important
- It is essential to keep an open mind
- Vaccination and screening are needed to achieve elimination threshold of cervical cancer.
Author competing interests – nil