Anal cytology in women with cervical intraepithelial or invasive cancer: interobserver agreement

Heráclio, Sandra A.; Pinto, Fátima Regina G.; Cahen, Kristiane; Katz, Letícia; Souza, Alex Sandro R.

doi:10.5935/1676-2444.20150051

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CYTOPATHOLOGY • J. Bras. Patol. Med. Lab. 51 (5) • Sep-Oct 2015 • https://doi.org/10.5935/1676-2444.20150051 linkcopy

Anal cytology in women with cervical intraepithelial or invasive cancer: interobserver agreement

Citologia anal em mulheres com neoplasia intraepitelial ou invasiva cervical: concordância interobservadores

Authorship SCIMAGO INSTITUTIONS RANKINGS

Introduction: Incidence rates of anal cancer have been rising worldwide in the last 20 years. Due to embryological, histological and immunohistochemical similarities between the anal canal and the cervix, routine screening with anal cytology for precursor lesions in high-risk groups has been adopted. Objective: To determine interobserver agreement for the diagnosis of anal neoplasia by anal cytology.

Material and methods: A cross-sectional observational study was conducted in 324 women with cervical intraepithelial or invasive cancers, for screening of anal cancer, from December 2008 to June 2009. Three hundred twenty-four cytological samples were analyzed by three cytopathologists. Cytological evaluation was based on the revised Bethesda terminology; samples were also classified into negative and positive for atypical cells. We calculated the kappa statistic with 95% confidence interval (95% CI) to assess agreement among the three cytopathologists.

Results: Interobserver agreement in the five categories of the Bethesda terminology was moderate (kappa for multiple raters: 0.6). Agreement among cytopathologists 1, 2 and 3 with a consensus diagnosis was strong (kappa: 0.71, 0.85 and 0.82, respectively).

Conclusion: Interobserver agreement in anal cytology was moderate to strong, indicating that cervical cytomorphological criteria are reproducible also in anal samples.

Key words:
early diagnosis; anus neoplasms; uterine cervical neoplasms

Cytopathological diagnosis	n	%
Squamous cell atypias	30	9.3
HGAIL	9	2.8
LGIEL	61	18.8
Within normal limits	204	63
Unsatisfactory	20	6.2
Total	324	100
Histopathological diagnoses
HPV	12	11.5
Anal intraepithelial lesion grade 1	8	7.7
Anal intraepithelial lesion grade 2	11	10.6
Anal intraepithelial lesion grade 3	3	2.9
Normal	24	23.1
SHME	24	23.1
SHME with vacuolization	10	9.6
Inflammatory	12	11.5
Total	104	100

	Consensus
	ASC	WNL	UNS	HGAIL	LGAIL	Total
Cytopathology 1
ASC	23	19	2	0	15	59
%	39	32.2	3.4	0	25.4	100
WNL	2	166	6	0	7	181
%	1.1	91.7	3.3	0	3.9	100
UNS	1	8	12	0	0	21
%	4.8	38.1	57.1	0	0	100
HGAIL	1	2	0	8	2	13
%	7.7	15.4	0	61.5	15.4	100
LGAIL	3	9	0	1	37	50
%	6	18	0	2	74	100
Cytopathology 2
ASC	12	2	0	0	4	18
%	66.7	11.1	0	0	22.2	100
WNL	6	189	2	0	7	204
%	2.9	92.6	1	0	3.4	100
UNS	0	9	18	0	1	28
%	0	32.1	64.3	0	3.6	100
HGAIL	2	0	0	6	4	12
%	16.7	0	0	50	33.3	100
LGAIL	10	4	0	3	45	62
%	16.1	6.5	0	4.8	72.6	100
Cytopathology 3
ASC	15	0	0	1	6	22
%	68.2	0	0	4.5	27.3	100
Carcinoma	1	0	0	0	0	1
%	100	0	0	0	0	100
WNL	9	194	0	1	10	214
%	4.2	90.7	0	0.5	4.7	100
Inflammatory	0	2	0	0	0	2
%	0	100	0	0	0	100
UNS	1	6	20	0	1	28
%	3.6	21.4	71.4	0	3.6	100
HGAIL	2	1	0	7	0	10
%	20	10	0	70	0	100
LGAIL	2	1	0	0	44	47
%	4.3	2.1	0	0	93.6	100
Multi-rater kappa						0.6

Consensus diagnosis
	Positive		Negative		Kappa	95% CI	p
	n	%	n	%	Kappa	95% CI	p
Cytopathologist 1
Positive	90	75	30	25	0.71	0.6-0.83	< 0.0001*
Negative	9	5.1	166	94.9	0.71	0.6-0.83	< 0.0001*
Cytopathologist 2
Positive	86	93.5	6	6.5	0.85	0.73-0.96	< 0.0001*
Negative	13	6.4	189	93.6	0.85	0.73-0.96	< 0.0001*
Cytopathologist 3
Positive	78	97.5	2	2.5	0.82	0.71-0.93	< 0.0001**
Negative	20	9.3	196	90.7	0.82	0.71-0.93	< 0.0001**

Histopathological diagnosis
	Positive		Negative		Kappa	95% CI	p
	n	%	n	%	Kappa	95% CI	p
Cytopathologist 1
Positive	25	37.3	42	62.7	0.17	0.01-0.33	0.14*
Negative	8	22.9	27	77.1	0.17	0.01-0.33	0.14*
Cytopathologist 2
Positive	26	40.6	38	59.4	0.16	0-0.32	0.03*
Negative	7	19.4	29	80.6	0.16	0-0.32	0.03*
Cytopathologist 3
Positive	21	38.2	34	61.8	0.14	-0.03-0.31	0.11*
Negative	11	23.4	36	76.6	0.14	-0.03-0.31	0.11*
Consensus
Positive	28	38.9	44	61.1	0.16	0.02-0.31	0.02**
Negative	5	16.1	26	83.9	0.16	0.02-0.31	0.02**

Cytopathologic diagnosis	Positive PCR		Negative PCR
Cytopathologic diagnosis	n	%	n	%
Atypias of undetermined significance	25	86.2	4	13.8
Low-grade anal intraepithelial lesion	60	98.4	1	1.6
High-grade anal intraepithelial lesion	9	100	0	0

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[TFN01] HGAIL: high-grade anal intraepithelial lesion; LGAIL: low-grade anal intraepithelial lesion; HPV: human papillomavirus; SHME: simple hyperplasia of the Malpighian epithelium.