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cervical cytology

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Information about cervical cytology
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pap

Published on September 22, 2011

Author: cyto786

Source: authorstream.com

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Slide 1: CERVICAL CYTOLOGY DR. RAVI JAIN Papanicolaou (Pap) stain: Papanicolaou (Pap) stain Alcohol dried; better for nuclear detail Stains ribosomes blue green, particularly in parabasal cells, mesothelial cells and metaplastic squamous cells Stains metabolically inactive cells pink, such as superficial cells Stains keratinized cells or thick specimens orange (benign or malignant) Fix quickly ; air dried smears are inadequate BASAL CELLS: BASAL CELLS Parent to all the cells in the mucosa Sampled rarely due to deep position & firm attachment to basement membrane Cohesive cluster of small regular cells with sparse green cytoplasm, oval nuclei & a high nuclear cytoplasmic ratio. Fine chromatin pattern. PARABASAL CELLS: PARABASAL CELLS The cells have a nucleus with finely granular chromatin. • The nuclei have a delicate membrane and no visible nucleolus. • The N:C is much higher than that of the intermediate cell. Predominate in atrophic smears from post menopausal females, post natal atrophy,high dose progesterone OCPs. INTERMEDIATE CELLS: INTERMEDIATE CELLS • large polygonal cells with ample pale green filmy cytoplasm folded at periphery. • The chromatin is finely granular and nucleoli are not visible. Progesterone causes cells to accumulate glycogen forming an irregular central deposit of pale yellow stained material. SUPERFICIAL CELLS: SUPERFICIAL CELLS The nuclei are small, dark, and pyknotic with no visible nuclear detail. The cytoplasm may be pink, slightly orange or blue (cyanophilic). Wisps of mucus and occasional neutrophils are present in the background. EPITHELIAL PEARLS: EPITHELIAL PEARLS Nests of benign epithelial cells known as epithelial pearls are sometimes seen in normal smears. Spindly small intermediate cells squamous cells with normal nuclei. ANUCLEATE SQUAMES: ANUCLEATE SQUAMES Mature superficial squamous cells with loss of nuclei. Indicate completion of keratinization. Inc in number shows hyperkeratosis, due to irritation- prolapse, pessary, infection- HPV, leukoplakia & in some cases cervical cancer. ENDOCERVICAL CELLS: ENDOCERVICAL CELLS Columnar cells with picket fence or honey comb appearance. Delicate cytoplasm, round nuclei with vesicular chromatin,with one or more nucleoli. Bare nuclei may accompany. CILIATED ENDOCERVICAL CELLS: CILIATED ENDOCERVICAL CELLS These cells have somewhat larger nuclei that stain darker. Slide 14: MULTINUCLEATED ENDOCERVICAL CELLS STRIPPED NUCLEI WITH INTRANUCLEAR INCLUSIONS Mature Squamous metaplasia: Mature Squamous metaplasia Note the spidery cytoplasmic processes, a feature that may be seen in metaplastic cells on conventional smears. Due to forceful removal of cells from the mucosa. SQUAMOUS METAPLASIA: SQUAMOUS METAPLASIA The presence of squamous metaplastic cells indicates that the transformation zone has been sampled (a minimum of 10 well-preserved endocervical or metaplastic cells is required for this quality indicator). TRANSFORMATION ZONE: TRANSFORMATION ZONE Smear of a young adult woman showing side by side secretory and non secretory ( young metaplastic ) endocervical cells. ENDOMETRIAL CELLS: ENDOMETRIAL CELLS Physiological in smears for the first 12 days. Endometrial cells are only reported in women 40yrs or over if the glandular component is present. In this case the age is 36 years and the patient is menstruating: thus the endometrial cells do not need to be reported. ENDOMETRIAL CELLS: ENDOMETRIAL CELLS DAY 1 of bleeding: cluster of endometrial cells in background of blood, squamous cells & debris ENDOMETRIAL CELLS: ENDOMETRIAL CELLS Day 6 of bleeding: spherical cluster of endometrial cells with the core formed by stromal cells and the periphery by poorly preserved large glandular cells EXODUS: EXODUS Smear taken during menstruation: cluster of normal endometrial cells with small dark nuclei, among squamous cells, polymorphs and numerous small macrophages . NEUTROPHILS: NEUTROPHILS Physiological in the mucus plug of cervix. Increased in cervicitis & vaginitis & cervical malignancy. May obscure the picture,liquid based preparation better to solve the problem. HISTIOCYTES: HISTIOCYTES Streaming pattern of single cells with round ovoid bean shaped cytoplasm,with eccentric round to oval nuclei and foamy cytoplasm. These cells possess fine cytoplasmic vacuoles that may resemble degenerative vacuoles sometimes found in normal metaplasia, ASC-H, and HSIL. LACTOBACILLI: LACTOBACILLI Normal vaginal flora Decreased with bacterial vaginosis More common in second half of menstrual cycle, pregnancy and diabetes mellitus HORMONAL EFFECTS ESTROGEN: HORMONAL EFFECTS ESTROGEN Estrogen promotes growth and maturation of stratified squamous epithelium. Smear has large,flat,dissociated eosinophilic squamous cells along with a cluster of endometrial cells. PROGESTERONE: PROGESTERONE Causes rapid desquamation of the topmost layers. Intermediate cells develop curled edges giving folded appearance. Cytoplasm often contains glycogen, staining yellow at the centre. MENOPAUSAL SMEAR: MENOPAUSAL SMEAR Intermediate navicular cells seen crowded. Boat shaped cells contain yellow deposits of glycogen that push the nucleus to the periphery. ATROPHIC SMEAR PATTERN: ATROPHIC SMEAR PATTERN Parabasal cells with seemingly enlarged pale nuclei. N:C ratio not altered. Inflammatory cells in background. ANDROGEN EFFECT: ANDROGEN EFFECT IN ADVANCED MENOPAUSE 70% 30% EARLY MENOPAUSE CHILD BEARING MATURATION ARREST vvvvvvvvvvvvvv: vvvvvvvvvvvvvv Bethesda System 2001 Specimen type Indicate conventional smear (Pap smear), liquid based preparation or other preparation (describe) Specimen adequacy: Specimen adequacy Assessment of specimen adequacy (satisfactory and unsatisfactory): 1 - Adequate number of squamous cells 2 -an adequate number of endocervical cells (at least 10 well-preserved endocervical or metaplastic cells) confirms sampling of transition zone. 3 - Specimen with more than 75% of cells obscured by inflammation and bacteria is unsatisfactory Unsatisfactory for evaluation Specimen rejected/not processed Specimen processed and examined, but unsatisfactory for evaluation of epithelial abnormality Slide 32: Interpretation/result Negative for Intraepithelial Lesion or Malignancy (NILM) Organisms • Trichomonas vaginalis • Candida species • bacterial vaginosis • Actinomyces species • Herpes simplex virus Slide 33: Other non-neoplastic findings - inflammation (includes typical repair) - irradiation - Intrauterine contraceptive device (IUD) • Glandular cells status post hysterectomy • Atrophy Other • Endometrial cells (in age >40 yrs; specify if “negative for squamous intraepithelial lesion”) Trichomonas vaginalis: Trichomonas vaginalis Trichomonas is a pear-shaped, oval to round, kite shaped cyanophilic organism . The nucleus is pale, vesicular and centrally located. Eosinophilic granules are often visible in the cytoplasm. In LBPs, the organisms tend to be smaller due to rounding, nuclei and cytoplasmic granules are better visualized and flagellae are often better preserved. Reaction to trichomonas: Reaction to trichomonas shows eosinophilic mature epithelial cells & darkly stained polymorphs Nuclei of epithelial cells are enlarged & hyperchromatic, with irregular chromatin pattern & perinuclear halo. Sec orangiophilia of cell cytoplasm may be seen. HSV: HSV "Ground-glass" appearance is due to intranuclear viral particles and enhancement of nuclear envelope caused by peripheral chromatin margination. ACTINOMYCES: ACTINOMYCES typical aggregates of pseudo-filamentous material. Smear from a woman with an IUD . BACTERIAL VAGINOSIS: BACTERIAL VAGINOSIS Gardenella vaginalis are seen in the background, mainly covering the squamous cells resulting in clue cells (arrows). No cytolysis. Polymorphs are absent or rare CLUE CELLS: CLUE CELLS MYCOSIS: MYCOSIS Fungal hyphae and yeast cells are seen. Seen with silver stain, or jones-marres stain. INFLAMMATORY CHANGES IN SQUAMOUS CELLS: INFLAMMATORY CHANGES IN SQUAMOUS CELLS Nuclear pallor & enlargement indicative of impending cell necrosis. INFLAMMATORY CHANGES IN SQUAMOUS CELLS: INFLAMMATORY CHANGES IN SQUAMOUS CELLS Perinuclear halo seen in trichomonas infection INFLAMMATORY CHANGES IN SQUAMOUS CELLS: INFLAMMATORY CHANGES IN SQUAMOUS CELLS Hyperchromasia of parabasal cells Some with nuclear fragmentation or apoptosis REACTIVE SQUAMOUS CELS: REACTIVE SQUAMOUS CELS Mild nuclear enlargement and no significant chromatin changes. INFLAMMATORY CHANGES IN ENDOCERVICAL CELLS: INFLAMMATORY CHANGES IN ENDOCERVICAL CELLS Presence of prominent nucleoli INFLAMMATORY CHANGES IN ENDOCERVICAL CELLS: INFLAMMATORY CHANGES IN ENDOCERVICAL CELLS Cytoplasmic vacoulation of the endocervical cells Reparative changes in endocervical cells: Reparative changes in endocervical cells Monolayer sheet of endocervical cells with orderly arrangement. Streaming effect is observed. Nuclei are enlarged with nucleoli but have smooth borders and are not hyperchromatic. IUD EFFECT: IUD EFFECT calcified debris characteristic of the condition RADIATION EFFECT: RADIATION EFFECT huge cytoplasmic vacoules seen in the squamous cells signify cell death. Slide 50: Epithelial Cell Abnormalities SQUAMOUS CELL • Atypical squamous cells - of undetermined significance (ASC-US) - cannot exclude HSIL (ASC-H) *Low grade squamous intraepithelial lesion (LSIL) - encompassing HPV/mild dysplasia/CIN I • High grade squamous intraepithelial lesion (HSIL) - encompassing: moderate and severe dysplasia/CIN2/CIN3/CIS - with features suspicious for invasion (if invasion suspected) • Squamous cell carcinoma COMPARISON OF CLASSIFICATIONS: COMPARISON OF CLASSIFICATIONS CIN GRADE WHO BSCC BETHESDA borderline ASCUS I Mild dysplasia Mild dyskaryosis Low grade SIL II Moderate dysplasia Moderate dyskaryosis High grade SIL III Severe dysplasia Severe dyskaryosis High grade SIL Epidermoid carcinoma ?invasive carcinoma Squamous carcinoma ASC-US: ASC-US Nuclear enlargement of 2.5x to 3x the area of a normal intermediate squamous cell nucleus Overall rate of ASC < 5% of all reported smears and that rate should not exceed 2-3 times the frequency of SIL. Subcategories: ASCUS- squamoid cell type or mature ASCUS- mature metaplastic type ASCUS- immature metaplastic ASCUS- in a setting atrophy ASCUS- with atypical parakeratosis KOILOCYTE (HPV): KOILOCYTE (HPV) Large squamous cell with enlarged hyperchromatic nucleus & large sharply demarcated perinuclear clear zone Slide 55: A) ASCUS in squamous cells demonstrating a mild degree of nuclear enlargement, hyperchromasia, and membrane irregularity. B) ASCUS in mature metaplastic squamous cells demonstrating nuclear enlargement. Slide 56: Atypical squamous cells of undetermined significance in an atrophic smear demonstrating nuclear enlargement. Slide 57: ASCUS in immature, metaplastic squamous cells ( arrow ) demonstrating nuclear enlargement, hyperchromasia, and irregular nuclear membranes. ASC-US: ASC-US Multinucleated cells with small perinuclear halo. Features are insufficient for an interpretation of LSIL. ASC-H: ASC-H Loosely cohesive metaplastic cells with increased N:C ratio. Differential includes reactive/ reparative metaplastic cells and HSIL ASC-H: ASC-H Less mature squamous cells/metaplastic cells with polygonal shape, and slightly enlarged nuclei with occasional nuclear contour irregularities. Boundary of ASC-US and ASC-H; differential includes CIN 2 ASC-H (NOS): ASC-H (NOS) ASC-H: NOS . Cohesive groups of atypical cells with mostly ill-defined cell borders. The nuclei vary in size with coarse chromatin; however, the nuclear details in most are relatively smudgy Slide 62: ASC-H ( FAVOUR HPV) Cohesive groups of hyperchromatic cyanophilic cells with ill-defined cell borders, which are straight with angulations better seen at periphery . N/C ratio is higher. Chromatin is smudgy. Some cells may show koilocytic space around nuclei LSIL: LSIL Large, multinucleated dysplastic cells with "mature" cytoplasm and distinct cell borders. Nucleus shows enlargement which is > 3X intermediate nuclei, hyperchromasia, pleomorphism of size and shape. No nucleoli seen. LSIL: LSIL Nuclear features are consistent with LSIL. HPV cytopathic effect or ?koilocytosis is also seen. LSIL: LSIL HPV nuclear and cytoplasmic changes (binucleation and koilocytosis) are consistent with LSIL. in addition to perinuclear cavitation, nuclear abnormalities as seen here are required to make an interpretation of LSIL. Nuclear size is only 2 times larger than intermediate nuclei, but chromatin pattern is granular and nuclear membranes are irregular. HSIL: HSIL Severely dysplastic cells on the left display a high nuclear to cytoplasmic ratio and irregular nuclear membranes. Moderately dysplastic cells on the right have similar nuclei and more cytoplasm. Note the nuclear membrane irregularities and abnormally distributed chromatin. HSIL: HSIL Syncytial arrangement (loss of polarity and cell borders) suggests carcinoma in situ . The cytoplasm is "non-metaplastic" Note also that the abnormal nuclei contain grooves- a feature that is not infrequently seen in HSIL. HSIL: HSIL A. Syncytial pattern. Hyperchromatic crowded groups of cells without distinct cell borders. The hyperchromatic nuclei vary in size and show coarsely granular chromatin B. Singly scattered (so called 'litigation') cells. Scattered, isolated, atypical cells show high N/C ratio. The nuclei have coarse chromatin without nucleoli PSEUDOKOILOCYTES: PSEUDOKOILOCYTES Glycogen in squamous cells can give the appearance of "pseudokoilocytosis". Nuclear abnormalities required for an interpretation of ASC-US/ LSIL are absent. Squamous cell ca: Squamous cell ca Dysplastic squamous cells with anisocytosis and anisonucleosis including keratinization and tadpole cells are diagnostic of invasive squamous cell carcinoma. Squamous cell ca: Squamous cell ca Cells on the left with scant cytoplasm display nuclei with irregularly distributed, coarsely granular chromatin and prominent nucleoli. On the right, lysed blood and a stripped nucleus, tumor diathesis, is evident. Slide 72: GLANDULAR CELL • Atypical - endocervical cells - endometrial cells - glandular cells • Atypical - endocervical cells, favor neoplastic - glandular cells, favor neoplastic • Endocervical Adenocarcinoma in situ • Adenocarcinoma - endocervical - endometrial - extrauterine - not otherwise specified (NOS) Atypical endocervical cells: Atypical endocervical cells Sheet of cells with enlarged round or oval nuclei with prominent nucleoli. Chromatin is finely granular and evenly distributed but occasional chromocenters are seen. Cell borders are well-defined. Mitotic figures are noted. Endocervical ca: Endocervical ca aggregate of abnormal cells with elongated hyperchromatic nuclei arranged in glandular strips that have nuclear pseudostratification and suggestion of a gland lumen. There is some suggestion of feathering at the periphery. BY : DR RAVI JAIN: THANK YOU BY : DR RAVI JAIN

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