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International Endocervical Adenocarcinoma Criteria and Classification

Validation and Interobserver Reproducibility

Hodgson, Anjelica, MD*,†; Park, Kay J., MD; Djordjevic, Bojana, MD*,†; Howitt, Brooke E., MD§; Nucci, Marisa R., MD; Oliva, Esther, MD; Stolnicu, Simona, MD#; Xu, Bin, MD, PhD*,†; Soslow, Robert A., MD; Parra-Herran, Carlos, MD*,†

The American Journal of Surgical Pathology: January 2019 - Volume 43 - Issue 1 - p 75–83
doi: 10.1097/PAS.0000000000001095
Original Articles

The current World Health Organization (WHO) classification for endocervical adenocarcinoma (EA) is based on descriptive morphologic characteristics; however, it does not fully reflect our current knowledge of the diverse pathogenesis of cervical glandular neoplasia. A novel classification system, the International Endocervical Adenocarcinoma Criteria and Classification (IECC), which incorporates etiology and biological behavior into the morphologic scheme, has been recently proposed. We aimed to validate the IECC by assessing its interobserver reproducibility in comparison to the WHO system. A cohort of 75 EAs was reviewed independently by 7 gynecologic pathologists and categorized following IECC and WHO criteria based on hematoxylin and eosin material alone and after immunohistochemistry results for p16, PR, p53, Napsin-A, vimentin, CDX2, and GATA3 were provided. Human papillomavirus (HPV) in situ hybridization and polymerase chain reaction results were compared with consensus diagnoses. IECC was superior to WHO in terms of interobserver agreement with κ=0.46 versus 0.3, respectively, on hematoxylin and eosin review and κ=0.51 versus 0.33, respectively, with immunohistochemistry. Under the IECC, 73 (97%) of EAs had majority agreement (≥4 reviewers in agreement) whereas 42 (56%) had perfect agreement (7/7 reviewers in agreement). Conversely, WHO showed majority agreement in 56 (75%) and perfect agreement in only 7 (10%) EAs. Reproducibility was poor in HPV-related WHO types (usual κ=0.36, mucinous not otherwise specified κ=0.13, intestinal κ=0.31, villoglandular κ=0.21) and good in major HPV-unrelated categories (gastric type κ=0.63, clear cell κ=0.81, mesonephric κ=0.5). Classification as per the IECC had excellent correlation with HPV status (by RNA in situ hybridization or polymerase chain reaction). We have shown that the IECC has superior interobserver agreement compared with the WHO classification system, and that distinction between HPV-related and HPV-unrelated EA can be made with good reproducibility and excellent prediction of HPV status. WHO morphologic variants of HPV-related EA are poorly reproducible. Conversely, agreement is high among important high-risk HPV-unrelated subtypes. Thus, our results further support replacing the current WHO classification with the IECC.

*Department of Laboratory Medicine and Pathobiology, University of Toronto

Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY

§Department of Pathology, Stanford Medical Centre, Stanford University School of Medicine, Stanford, CA

Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School

Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA

#Department of Pathology, University of Medicine and Pharmacy of Targu Mures, Targu Mures, Romania

Conflicts of Interest and Source of Funding: Supported in part through the NIH/NCI Cancer Center Support Grant P30 CA008748 (KJ Park and RA Soslow).The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Correspondence: Carlos Parra-Herran, MD, Department of Laboratory Medicine and Pathobiology, University of Toronto, 2075 Bayview Ave, Toronto, ON, Canada M4N3M5 (e-mail:

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