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2017, Volume 33, Number 3, Page(s) 177-191     
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DOI: 10.5146/tjpath.2017.01400
Diagnostic and Treatment Reproducibility of Cervical Intraepithelial Neoplasia / Squamous Intraepithelial Lesion and Factors Affecting the Diagnosis
Arzu SAĞLAM1, Alp USUBÜTÜN1, Anıl DOLGUN2, George L. MUTTER3, M. Coşkun SALMAN4, Olcay KURTULAN1, Aytekin AKYOL1, Eylem AKAR ÖZKAN5, Sema BAYKARA6, Dilek BÜLBÜL7, Zerrin CALAY8, Funda EREN9, Derya GÜMÜRDÜLÜ10, Nihan HABERAL5, Şennur İLVAN8, Şeyda KARAVELİ11, Meral KOYUNCUOĞLU12, Bahar MÜEZZİNOĞLU13, Kamil Hakan MÜFTÜOĞLU14, Özlem ÖZEN5, Necmettin ÖZDEMİR15, Elif PEŞTERELİ11, Çağnur ULUKUŞ12, Osman ZEKİOĞLU15
1Department of Pathology, Hacettepe University, Medical Faculty, ANKARA, TURKEY
2Department ofBiostatistics, Hacettepe University, Medical Faculty, ANKARA, TURKEY
3Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
4Department of Obstetrics & Gynecology, Hacettepe University, Medical Faculty, Ankara, Turkey
5Department of Pathology, Baskent University, Medical Faculty, ANKARA, TURKEY
6Uludag University, Medical Faculty, BURSA, TURKEY
7Etlik Zubeyde Hanim Women’s Health Teaching and Research Hospital, ANKARA, TURKEY
8Istanbul University Cerrahpasa, Medical Faculty, ISTANBUL, TURKEY
9Marmara University, Medical Faculty, ISTANBU L, TURKEY
10Cukurova University, Medical Faculty, Ada na, Turkey, 11Akdeniz University, Medical Faculty, ANTALYA, TURKEY
12Dokuz Eylül University, Medical Faculty, IZMİR, TURKEY
13Kocaeli University, Medical Faculty, KOCAELİ, TURKEY
14Zekai Tahir Women’s Health Teaching and Research Hospital, ANKARA, TURKEY
15Ege University, Medical Faculty, IZMİR, TURKEY
Keywords: Interobserver reproducibility, SIL, CIN, Diagnosis, Gynecologist

Objective: Inter-observer differences in the diagnosis of HPV related cervical lesions are problematic and response of gynecologists to these diagnostic entities is non-standardized. This study evaluated the diagnostic reproducibility of “cervical intraepithelial neoplasia” (CIN) and “squamous intraepithelial lesion” (SIL) diagnoses.

Material and Method: 19 pathologists evaluated 66 cases once using H&E slides and once with immunohistochemical studies (p16, Ki-67 and Pro-ExC). Management response to diagnoses was evaluated amongst 12 gynecologists. Pathologists and gynecologists were also given a questionnaire about how additional information like smear results and age modify diagnosis and management.

Results: We show moderate interobserver diagnostic reproducibility amongst pathologists. The overall kappa value was 0.50 and 0.59 using the CIN and SIL classifications respectively. Impact of immunohistochemical evaluation on interpretation of cases differed and there was lack of statistically significant improvement of interobserver diagnostic reproducibility with the addition of immunohistochemistry. We saw that choice of treatment methods amongst gynecologists varied and overall concordance was only fair to moderate. The CIN2 diagnostic category was seen to have the lowest percentage agreement amongst both pathologists and gynecologists. We showed that pathologists had diagnostic “styles” and gynecologists had management “styles”.

Conclusion: In summary each pathologist had different diagnostic tendencies which were affected not only by histopathology and marker studies, but also by the patient management tendencies of the gynecologist that the pathologist worked with. The two-tiered modified Bethesda system improved diagnostic agreement. We concluded that immunohistochemistry should be used only to resolve problems in select cases and not for every case.

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