Is koilocytic change enough for LSIL dx?

Koilocyte = dysplasia. There are a lot of nuances, but in general if it's a koilocyte or the nucleus is big and dark it's dysplasia (remember reading this somewhere - cibas?).

the attending's mood.

no, it's a fair question. i'm not a cyto person, and i struggled with this too sometimes. darker nuclei, higher N/C, more "wrinkled" nuclear membrane. those are things i found helpful in calling LSIL. if i'm recalling correctly, definitive koilocytosis (don't get fooled by the pseudohalos) warrants a diagnosis of LSIL. remember, paps are screening tests, so i sometimes saw attendings make their diagnosis based on what they thought best for the patient. there are borderline cases, and if you truly believe the patient is best served by going for colposcopy rather than the HPV testing (which is the standard f/u for an ASC-US), then diagnose LSIL.

nice to see a question actually related to diagnosis!

Depends on if you are a surgical pathologist or a cytopathologist. In surgpath koilocyte = LSIL. In cytopath you can have HPV changes that are not dysplastic. Also depends on whether your attending likes you.

mlw03 said:

remember, paps are screening tests

Click to expand...

+1. The best advice I ever got about paps (from one of the best pathologists/cytopathologists I've ever known) was if the pap is abnormal it doesn't matter what you call it, as long as you don't call it "NIL." This will get the patient more followup which is what you want. BTW, I hate paps. I'd rather diff 20 bone marrows than read a tray of paps.

In cytology, true koilocytosis is sufficient for LSIL, because the decision was made in cytology to have a three-tier system and koilocytes are too abnormal to be NILM, too low to be HSIL. The Bethesda system manual confirms this. So those who have said this are correct.

Those who say that koilocytosis=dysplasia (implying that a surgical pathologist should diagnose dysplasia on a biopsy of that area) are not exactly correct (IMHO). There are many surg path cases with excellent koilocytes that would not qualify for the lowest grade of dysplasia, CIN 1; for that you need architectural evidence of dysmaturation. Look at your true CIN 1 (or higher) cases and you will see a jumbled or indiscernible basal layer and mitotic figures higher than the parabasal layer, which is the highest they should ever be in benign. Koilocytes will usually be present but they are not the diagnostic cells. In cyto, you don't have the architecture, or the underlying cells, so that is why koilocytes are sufficient for LSIL. You get a lot of false positives. That's the nature of a screening test.

I know you were really asking if a surg path biopsy with koilocytes can be called LSIL. Sure, if you are in a place where cytology terminology is used for surgicals. There are many places where this is customary and it isn't exactly wrong, but I think you are losing information if you don't further classify the diagnosis. Is it LSIL (CIN 1) or LSIL (cytopathic changes of HPV infection)? The person with the latter has a lesion, sure--but they do not have dysplasia as most surgical pathologists would define it.

And by the way, the phrase "if it's big and it's dark, it's dysplasia" is in big DeMay and for cytology training, is probably not incorrect, I actually find it rather memorable and helpful for Paps.

Heh. The question was REALLY about ASC-US v. LSIL. This distinction has to do with how certainly the presence of a SIL can be established from the smear. ASC-US is for cases where the features are not quite sufficient for LSIL, usually due to the presence of inflammation/organisms (causing reactive changes that mimic LSIL) or a quantitatively small amount of the abnormal finding. In other words: ASC-US cells are too small or few for LSIL, too big to ignore.

Same thing for ASC-H, you know. It is not intermediate between LSIL and HSIL. ASC-H means your differential was HSIL versus NILM. The Bethesda system has no formal way to tell the clinician that your differential was LSIL vs. HSIL, which is a whole discussion unto itself.

Ombret said:

The Bethesda system has no formal way to tell the clinician that your differential was LSIL vs. HSIL, which is a whole discussion unto itself.

Click to expand...

We generally do "LSIL, A more severe process cannot be excluded, Colposcopic biopsy is recommended" in that case. I guess that is not technically Bethesda-approved, but it seems to work ok.

All of this makes me long for the day when HPV vaccine has fully kicked in and pap smear cytopathologists will be as useful as syphilisologists.

pathstudent said:

All of this makes me long for the day when HPV vaccine has fully kicked in and pap smear cytopathologists will be as useful as syphilisologists.

Click to expand...

Will vaccination completely end pap screening, or will it still be useful in some circumstances?

In theory, you could potentially vaccinate against all known* high-risk strains of HPV and eliminate all** new cases of cervical dysplasia/carcinoma.

Gardasil protects against only 2 high-risk strains (16 & 18), which admittedly cause >80-90% of cancers.

So there should be a drop in dysplasias/cancer as more people get vaccinated in the short-to-mid term. Eventually, though I imagine the less common high-risk strains will become more common, over, say, a 10-20 year period, because people will still be engaging in high-risk sexual behaviors.

So I can't imagine that cervical screening will go away, although I hope at some point during my career to be able to quit looking at paps and instead have molecular screening.

* This assumes that we will be able to characterize new/mutated strains before they infect people.
**This ignores the fact that a certain (small) population of patients never seroconvert after vaccination, and thus gain no protection.

Enkidu said:

Will vaccination completely end pap screening, or will it still be useful in some circumstances?

Click to expand...

Let's hope so. Think about how much time and dinero it would save.

Pap smears would probably only be done in patients with symtopms.

Only about 25 percent of women are even getting the vaccine. Its been a dog for merck.

One provision of the health care law is for insurance to be forced to cover HPV testing in 2013 along with birth control etc. Guess obama wants no one to be able to afford health insurance so we can go to a one payer system (gov).

Pretty soon our health insurance is gonna run us about 10,000 dollars a year. Just look at how much cervical cancer is costing. HPV vaccines, image guided paps, hpv testing, p16.... I am still in the camp that a conventional pap test once a year was getting the job done pretty cheap. Now it is overkill.

WEBB PINKERTON said:

Only about 25 percent of women are even getting the vaccine. Its been a dog for merck.

One provision of the health care law is for insurance to be forced to cover HPV testing in 2013 along with birth control etc. Guess obama wants no one to be able to afford health insurance so we can go to a one payer system (gov).

Click to expand...

It is unfortunate that the vaccine has not become more widespread. I guess between the religious idiots who didn't like the implication that it would "encourage promiscuity" (heaven forbid we try to prevent cancer at the cost of making unprotected sex very slightly safer with respect to one specific disease!!), the treehugging idiots who think the big bad government is secretly covering up data that vaccines are full of dangerous chemicals and will give their children autism and the cost for anyone older than their teens to get it (I think I was quoted around $350) it hasn't done very well. I don't usually have any desire to argue with people about "controversial" issues, but listening to this nonsense from parents who refuse to get their children vaccinated (without a legitimate reason like immunocompromise) makes me want to punch them in the face. Repeatedly.

As a woman, I also think that the recommendation by the Institute of Medicine that birth control should be completely covered by insurance companies is long overdue. Even from a cold-blooded, insurance company cost-analysis perspective, I have to assume that the cost of covering cheap, generic oral contraceptives for their young female members would be vastly less expensive than paying for the unintended pregnancies they would prevent.

Guess I am old school. I believe it a couple's responsibility to prevent unintended pregancies rather than make others pay. Heck, I love to run. Why doesnt my insurance pay for running shoes for everyone? Maybe I could come up with some cost/benefit analysis that shows less health care costs due to people being so fat. Of course there is no guarantee that the shoe will end up in the hands of people that need/will use them. Same for birth control. You will still see a ton of unwanted pregnancies. More children=more aid unfortunantly.

After the vaccine hit the market, I got our pap and tissue requisitions modified to include a box to mark if a woman had been vaccinated. I've been suprised the number of high grade dysplasias we have seen in vaccinated women. Even our dysplasia rates in general are higher now than pre-vaccine days.

Euchromatin said:

It is unfortunate that the vaccine has not become more widespread. I guess between the religious idiots who didn't like the implication that it would "encourage promiscuity" (heaven forbid we try to prevent cancer at the cost of making unprotected sex very slightly safer with respect to one specific disease!!), the treehugging idiots who think the big bad government is secretly covering up data that vaccines are full of dangerous chemicals and will give their children autism and the cost for anyone older than their teens to get it (I think I was quoted around $350) it hasn't done very well. I don't usually have any desire to argue with people about "controversial" issues, but listening to this nonsense from parents who refuse to get their children vaccinated (without a legitimate reason like immunocompromise) makes me want to punch them in the face. Repeatedly.

As a woman, I also think that the recommendation by the Institute of Medicine that birth control should be completely covered by insurance companies is long overdue. Even from a cold-blooded, insurance company cost-analysis perspective, I have to assume that the cost of covering cheap, generic oral contraceptives for their young female members would be vastly less expensive than paying for the unintended pregnancies they would prevent.

Click to expand...

It makes me want to punch people in the face who think I have to pay for someone else's "needs" because of their own "idea" (or some government panel's "idea") or (some crooked politician/corporation/lobbiests-induced "idea").

I will pay for my own "needs" and "ideas" and CHOOSE to pay for my own favorite charities that I think are worthwhile. Not someone elses. Thank you very much. This used to be the land of the free.

Thrombus said:

It makes me want to punch people in the face who think I have to pay for someone else's "needs" because of their own "idea" (or some government panel's "idea") or (some crooked politician/corporation/lobbiests-induced "idea").

I will pay for my own "needs" and "ideas" and CHOOSE to pay for my own favorite charities that I think are worthwhile. Not someone elses. Thank you very much. This used to be the land of the free.

Click to expand...

Interesting reaction. When you pay your insurance premiums you are necessarily paying for other peoples care. Does it bother you so much that some is going to pay for a woman's birth control?

I don't think that paying an insurance premium counts as a charity.

New study (of course funded by Roche) suggests that HPV testing alone is as good if not better than Pap....the future demise of Pap smears? Don't think so, given the cost..and this evidence is funded by Roche so I take it with a large grain of salt.

http://yourlife.usatoday.com/health...-of-cervical-cancer-than-pap-smear/50105814/1

Thrombus said:

... will pay for my own "needs" and "ideas" and CHOOSE to pay for my own favorite charities that I think are worthwhile. Not someone elses. Thank you very much. This used to be the land of the free.

Click to expand...

LOL!!!

As one famous Libertarian Atheist recently remarked, "Try not paying your taxes".

You want to be "free"? Go live on a boat out in the ocean.

Otherwise, shut yer trap and submit to our (Quasi-)Benevolent Overlords.

Enkidu said:

Interesting reaction. When you pay your insurance premiums you are necessarily paying for other peoples care. Does it bother you so much that some is going to pay for a woman's birth control?

I don't think that paying an insurance premium counts as a charity.

Click to expand...

Insurance is a product that I CHOOSE to buy. Unfortunately my choices are limited but in a perfect world I would choose a policy that gave me negotiated rates, a high deductable, no co-pays (I don't need the insurance to pay for my office visit -- this adds huge costs IMO), high maximum lifetime benefit, and 5K or so annual out of pocket maximum. I would not want my insurance to pay for things such as women's birth control or men's viagra -- I don't think there is need for a third party to get involved in these transactions as it only adds to the costs. I buy insurance for the INSURANCE part of it.

Unfortunately, my perfect policy does not exist so I have to find the best one available. The government seems to think we need a one size fits all model to which I am adamently opposed.

My charities do much more good than the government bureaucrats self-promoting ones do in my opinion. I like charities that buy school clothes, lunches, and supplies for low-income children as an example. I view government sponsored charities that subsidize cable TV, cigarettes, and alcohol for the already unhealthy and addicted with disdain.

KluverB said:

LOL!!!

As one famous Libertarian Atheist recently remarked, "Try not paying your taxes".

You want to be "free"? Go live on a boat out in the ocean.

Otherwise, shut yer trap and submit to our (Quasi-)Benevolent Overlords.

Click to expand...

Misrepresentation of my views, noted. Strike 1.

Thrombus said:

Insurance is a product that I CHOOSE to buy. Unfortunately my choices are limited but in a perfect world I would choose a policy that gave me negotiated rates, a high deductable, no co-pays (I don't need the insurance to pay for my office visit -- this adds huge costs IMO), high maximum lifetime benefit, and 5K or so annual out of pocket maximum. I would not want my insurance to pay for things such as women's birth control or men's viagra -- I don't think there is need for a third party to get involved in these transactions as it only adds to the costs. I buy insurance for the INSURANCE part of it.

Unfortunately, my perfect policy does not exist so I have to find the best one available. The government seems to think we need a one size fits all model to which I am adamently opposed.

My charities do much more good than the government bureaucrats self-promoting ones do in my opinion. I like charities that buy school clothes, lunches, and supplies for low-income children as an example. I view government sponsored charities that subsidize cable TV, cigarettes, and alcohol for the already unhealthy and addicted with disdain.

Click to expand...

Too bad health insurance companies are exempt from anti-trust laws.
We are pretty much screwed. Hardly any competition. I honestly think Obama and his people want to kill the industry off and go to a single payer (gov) system. This health care bill is a job killer. Businesses aren't gonna want to hire people with all these added costs. The women who should be getting birth control wont (the poor) since they get more aid for having more children.

WEBB PINKERTON said:

Too bad health insurance companies are exempt from anti-trust laws.
We are pretty much screwed. Hardly any competition. I honestly think Obama and his people want to kill the industry off and go to a single payer (gov) system. This health care bill is a job killer. Businesses aren't gonna want to hire people with all these added costs. The women who should be getting birth control wont (the poor) since they get more aid for having more children.

Click to expand...

Competition isn't necessarily beneficial in health insurance, at least to health care consumers. Health insurers barter down prices by using their market share, a great example being medicare/medicaid. Increased competition might result in decreased bargaining power in any one insurance company and higher health care costs for consumers.

On the other hand, absent competition, there is little incentive for health insurers to minimize administrative costs. A single-payer system, while having the strongest possible power to bargain for lower costs for consumers, is also mostly likely to have wasteful administrative costs.

In addition to the intrinsic complexities of the health insurance market, the government has mandated that all patients receive emergency treatment regardless of their ability to pay. This is a further perversity that allows people to not buy insurance at all and be assured a treatment. They can just get their routine care from an emergency room.

This is the essential dilemma that health reform was trying to solve, if we want to mandate universal emergency room treatment, we have to mandate universal coverage. But if we don't mandate universal emergency room treatment, then we are essentially allowing poor people to simply die on the street.

I'm not advocating any particular view on how health care should be regulated, but it's clear that health insurance is a pathological market and normal free-market platitudes will not work. I think that Obama's health care law addresses the basic flaws in the system and is an improvement in its broad structure (i.e. EMTALA requires an insurance mandate). There may be better ways to regulate how businesses provide coverage or details like that, but those details can be evaluated as problems arise and hopefully ironed out in the normal legislative process (if our system is ever capable of passing laws again).

As for the effect of the new law on physician reimbursement, to be honest its not clear to me. Is it supposed to decrease? I imagine that some specialties may do better because their patients will now have insurance.

I'd love to get rid of insurance all together and go to pay for service but that aint happening. Right now everyone plays with house money and we have a TON of waste. You see it everyday in the lab. Heck, if we eliminated all the waste in pathology, unnecessary biopsies, immunos etc, the job market for pathologists would be even worse.

WEBB PINKERTON said:

I'd love to get rid of insurance all together and go to pay for service but that aint happening. Right now everyone plays with house money and we have a TON of waste. You see it everyday in the lab. Heck, if we eliminated all the waste in pathology, unnecessary biopsies, immunos etc, the job market for pathologists would be even worse.

Click to expand...

If we were on a pay for service system with no insurance, how much do you think you would get paid? The answer: nothing.

To me, this is a quantitative difference. If you have enough LSIL cells, you call it LSIL. If you dont have enough, and you want to raise a flag, you call it ASC-US. I know that many people call anything that looks remotely atypical ASC-US. But thats a different story.....

.