The authors A. Schneider and P. Hillemanns welcome the revision of the previous Munich II cytology nomenclature and its international harmonization. However, they criticize statements by the authors of Munich III about the contribution Munich III can make towards improving communications between doctors, avoiding unnecessary follow-up examinations and therapies, and reducing subsequent costs. The authors also denounce a lack of evidence and criticize basing recommendations on individual cytological diagnostic groups; they recommend that the Munich III Nomenclature be simplified
in analogy to the Bethesda System (TBS). They ignored the importance of the revised cytological nomenclature of Munich III for colposcopic diagnosis and for interventional colposcopy of precancerous squamous and glandular cells of the cervix and vagina.
The Board of the Study Group for Cervical Pathology and Colposcopy (AG-CPC) is of the opinion that the Munich III Nomenclature represents a considerable improvement compared to Munich II and TBS classifications of cytological abnormalities.
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Munich II was not used systematically in Germany. In some laboratories, the unofficial category IIw (IIk) was the most common finding, but this category did not appear in other laboratories. Its morphological characteristics had never been defined. For this reason it could never be included in official statistics. Because the forte of colposcopy is not screening but the diagnosis of abnormal cytological findings, colposcopic diagnoses did not refer to clearly defined cytological call changes. In the past, this has led some authors to water down their assessments and
their scientific analyses of data. In some publications, category IIw was assigned to screening for cervical cancer and to colposcopy investigations of unremarkable cytological findings, but sometimes also to the TBS category ASCUS.
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The previous IIID category (Munich II) included both low-grade and medium dysplasias and corresponded to CIN 1 and CIN 2. Morphological investigations and scientific data have shown that colposcopy which identifies “minor changes” (colposcopic terminology of the 2011 IFCPC Nomenclature, Rio 2011) cannot differentiate low-grade dysplasias (CIN 1) and HPV positivity from physiological findings (including metaplasias) (limited discriminatory power, low AUC value in ROC analysis). Medium-grade dysplasias (category IIID2 in Munich III) are more likely to present as “major
changes” in colposcopy (colposcopic terminology of the 2011 IFCPC Nomenclature, Rio 2011), which will require closer monitoring than category IIID1 (Munich III) or colposcopic “minor changes”.
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With its HSIL category, TBS does not differentiate ctyologically between medium-grade and high-grade dysplasias which correspond to CIN 2 and CIN 3, respectively. Category IV a (Munich III) which consists mainly of “major changes” visible on colposcopy (high selectivity, high AUC value in ROC analysis) offers a better differentiation between the different biological behaviors of high-grade CINs than TBS does. Remission can occur with CIN 2 (category IIID2 in Munich III), which means that, depending on the colposcopic findings (localization, size and extent of the lesion,
minor or major changes), surgery may not be mandatory.
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The authors of the Comments ignored the importance of glandular cell changes which were newly included in Munich III; in particular, they did not mention ACIS or adenocarcinomas which have an incidence of around 18 %. The simplification the authors demand would hamper the urgently needed colposcopic assessment and classification of glandular lesions. The current colposcopic terminology is only valid for CINs and squamous cell carcinomas. Munich III has remedied this deficiency of Munich II, which omitted glandular cell changes and in the past could result in colposcopy
findings being classed as less serious. The new cytological nomenclature of Munich III will thus contribute to developing colposcopic criteria for a colposcopic nomenclature for ACIS and adenocarcinomas using newly included and clearly defined cellular criteria for glandular lesions.
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Even though the cytological nomenclature in Munich III does not correspond to that of TBS in certain significant areas, it can be rendered into TBS terminology, making it possible to carry out high-level colposcopy research and clinical studies in Germany with results that can be published in international journals. The revision and simplification of Munich III demanded by the authors would undo the efforts that have been made to make colposcopy in Germany internationally reputable again.
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We find the criticism directed by the authors against recommendations based on cytological findings incomprehensible with regard to the use of colposcopy for diagnosis. Colposcopy is the only method which can be used to localize precancerous lesions or early stage (vaginal/cervical) cancers and describe their extent and size. This means that colposcopy is indicated for all abnormal cytological findings.
In summary, the cytological nomenclature of Munich III, which will come into general use from July 2014, offers considerable benefits for the routine use of colposcopy in practice. Clearly defined, suspicious cell changes can be assigned without difficulty to one of the categories described in the colposcopic terminology of the 2011 IFCPC Nomenclature (Rio 2011). The inclusion of glandular changes in Munich III, identified by the suffix (g), means that the colposcopic characteristics of glandular precancerous lesions (ACIS) and cervical adenocarcinomas can be reappraised for the
first time to create a consistent colposcopic nomenclature for non-squamous cell carcinomas. Munich III with its categories IIID1 and IIID2 and subsequent colposcopic assessment based on the criteria of IFCPC Colposcopy Nomenclature (Rio 2011) gives a much better picture of the biological behavior of the various CIN categories than TBS does with LSIL and HSIL.
The Board of the AG-CPC recommends that gynecologists use both the revised cytological classification (Munich III) and the international colposcopic terminology of the 2011 IFCPC Nomenclature (Rio 2011).
For the Authors:
Prof. Dr. med. W. Kühn
Gynecologist and obstetrician
Pathologist
Member of the Board and Deputy Chairman of the AG-CPC
and
Dr. Friederike Gieseking
Gynecologist
Member of the Board of the AG-CPC
