PAP SMEAR IN CERVICAL CYTOLOGY

PRESENTED BY : DR. BISWAJEETA SAHAPG STUDENT,DEPT. OF PATHOLOGY,

KIMS,BHUBANESWAR

HISTORY

DR.GEORGE PAPANICOLAOU

BETHESDA SYSTEM

The first workshop was held in 1988, to reduce widespread confusion among laboratories and clinicians created by the use of multiple classification systems and inconsistently defined numerical grading conventions.

Earlier versions of bethesda include 3 categories of adequacy:

Satisfactory Unsatisfactory Borderline.The 2001 bethesda system eliminates the borderline

category. To provide a clearer indication of adequacy specimens are now designated as “satisfactory” or “unsatisfactory”.

Cytological identification of epithelial cells

Transformation zone and squamocolumnar junction

Area of metaplastic epithelium proximal to the original squamocolumnar junction is referred to as transformation zone since it is an area of epithelial instability.

OTHER COMPONENTS OF CERVICAL SMEAR Endometrial cells Neutrophils,basophils,eosi

nophils,lymphocytes Macrophages Spermatozoa Contaminants.

PREPARATION OF PAP SMEAR.

Conventional pap smear

Liquid based preparations

SPECIMEN ADEQUACYMinimum squamous cellularity criteria Conventional smear-8000 to 12000 well

preserved, well visualised squamous cells. Liquid based prep-min 5000.

Endocervical zone component Atleast 10 well preserved endocervical or

squamous metaplastic cells ,singly or in clusters. If high grade cancer is present,it is not necessary

to report presence or absence of transformation zone component.

SATISFACTORY:1. Describes presence or absence of endocervical/transformation

zone component and any other quality indicators.2. Any specimen with abnormal cells (ASC-US,AGC or worse)is by

definition satisfactory for evaluation.

UNSATISFACTORY:

3. Rejected specimen-not processed because(specimen not labelled,slide broken, patient particulars not mentioned etc.)

4. Fully evaluated, unsatisfactory specimen-specimen processed and examined, but unsatisfactory for evaluation of epithelial abnormality because of-obscuring blood, inflammatory cells,etc.

5. Specimens with more than 75% of squamous cells obscured should be termed unsatisfactory.

6. When 50-75% cells are obscured,a statement describing the specimen as partially obscured should be made.

DIAGNOSTIC CATEGORIESNon

neoplastic

neoplastic

Organisms:•Trichomonas•Candida•Chlamydia•HSV•HPV•CMV

Other:•Reactive- *inflammation *radiation *IUD•Glandular cells post hysterectomy•Atrophy.

Epithelial cell abnormality

Squamous cell:•Atypical squamous cells(ASC) *ASCUS *ASC-H•Squamous intraepithelial lesion *LSIL *HSIL•Squamous cell ca *keratinising *non-keratinising

Glandular cell abnormalities:•Atypical *endocervical *endometrial *glandular•Atypical *endocervical cells favour neoplastic. *glandular cells favor neoplastic•Endocervical ca in situ•Adenooca *endocervical *endometrial *extrauterine *nos

ATYPICAL SQUAMOUS CELLS(ASC)

Interpretation af ASC requires that cells demonstrate 3 features-

Squamous differentiation Increased N/C ratio Minimal nuclear hyperchromasia,chromatin

clumping,irregularity,smudging or multinucleation

ATYPICAL SQUAMOUS CELLS OF UNDETERMINED SIGNIFICANCE

Nuclei approx 2 and 2.5 times area of nucleus of intermediate cells

Slightly increased N/C ratio. Minimal hyperchromasia,irregilarity in chromatin

distribution or nuclear shape.

ATYPICAL SQUAMOUS CELLS-CANNOT EXCLUDE HSIL

Include 2 categories Small cells with high N/C ratio-atypical metaplasia *cells occur singly or in small fragments of less than 10 cells. *cells size of metaplastic cells,nuclei about 1.5 to 2.5 times

larger than normal. Crowded sheet pattern- *crowded cells,nuclei show loss of polarity or difficult to

visualize. *dense cytoplasm, polygonal cells and fragments with sharp

linear edges generally favor squamous over glandular differentiation.

LSIL

Mature type cytoplasm Large cell size,increased N/C ratio. Nuclear enlargement more than 3 times the area of normal

intermediate nuclei Bi and multinucleation Chromatin uniformly distributed. Nucleoli generally absent Nuclear membrane slightly irreguilar distinct cytoplasmic borders. Koilocytosis.

ASCUSLSIL

INFLAMMATION

HSIL

Less mature than cells in LSIL. Nuclear hyperchromasia accompanied by variations in

nuclear size and shape. Degree of nuclear enlargement more variable Nuclear membrane quite irregular with indentations and

grooves Nucleoli absent,occassionally present cytoplasm immature,lacy,delicate or densely metaplastic

SQUAMOUS CELL CARCINOMA

KERATINISING1. relatively few cells present.2. Marked variation in cell size and shape,wiith caudate , spindle

cells and tadpole cells3. Marked variation in nuclear size, irregular nuclear membrane,

numerous dense opaque nuclei.4. Coarsely granular chromatin with parachromatin clearing.

5. Tumor diathesis may be present, less than non keratinizing.

NON KERATINISING-1. Cells occur singly or in syncitial aggregate with poorly

defined cell borders.2. Smaller than HSIL.3. Marked irregular distribution of coarsely clumped

chromatin.4. A tumour diathesis consisting of necrotic debris and old

blood.

ATYPICAL ENDOCERVICAL CELLS NOS Cells in sheets and strips, cell crowding, nuclear overlap. Nuclear enlargement upto 3 to 5 times area of normal

endocervical nuclei. Some variation in nuclear size and shape. Mild hyperchromasia Nucleoli may be present Mitosis rare Cytoplasm fairly abundant, N/C ratio increased Distinct cell border

ATYPICAL ENDOMETRIAL CELLS

Cells occur in small groups ,usually 5-10 cells/group. Nuclei slightly enlarged Mild hyperchromasia Small nucleoli Scant cytoplasm,ocassionaly vacuolated Ill defined cell borders.

ENDOCERVICAL CARCINOMA IN SITU

Cells occur in sheets,clusters,strips and rosettes with nuclear crowding and overlap, loss of honeycomb pattern.

palisading nuclear arrangement with feathering Enlarged. Stratified nuclei. Hyperchromasia Nucleoli small, inconspicuous Mitosis and apoptosis seen N/C ratio increased,cytoplasm and mucin diminished Abnormal squamous cells may be present

ENDOCERVICAL ADENOCARCINOMA

Abundant abnormal cells,typically with columnar configuration

Single cells,2dimensional sheets or 3 dimensional clusters and syncitial aggregates commonly seen

Enlarged pleomorphic nuclei,parachromatin clearing,nuclear membrane irregularities.

Macronucleoli present Cytoplasm finely vacuolated Necrotic tumour diathesis may be seen

TRICHOMONAS Pear shaped,oval,cyanophilic organisms,15-30μ Pale vesicular eccentrically located nucleus. Eosinophilic cytoplasm granules centrally. Inflammatory changes.

GARDNERELLA VAGINALIS Clue cells Mixed bacteria,mainly coccoid Neutrophilic satellitosis.

CANDIDA Double contoured pale pink hyphae and pseudohyphae Pseudohyphae appear septate Spores are eosinophilic Inflammatory changes variable

HERPES SIMPLEX Swollen nuclei with multinucleation. Ground glass chromatin with prominent nuclear membrane

and nuclear inclusions(tombstones). Nuclear moulding.

HUMAN PAPILLOMA VIRUS Koilocytosis-superficial and intermediate cells Multinucleation Nuclear swelling and degeneration Keratotic spikes,pearls and rafts Single dyskeratotic cells.

INFLAMMATIONCHANGES IN SQUAMOUS EPITHELIAL CELLS- Cytoplasmic abnormalities *vacuolation *perinuclear halo *altered staining *abnormal keratinisation Changes in nucleaus- *wrinkling of nuclear membrane *multinucleation *chromatin degenerationCHANGES IN ENDOCERVICAL CELLS- Cytoplasmic degeneration Nuclear variation

RADIATION Cell size markedly increased without increase in N/C ratio. Nuclei show degenerative changes Bi or multinucleation Prominent single or multiple nucleoli Cytoplasmic vacuolation

INTRAUTERINE DEVICES Endometrial shedding at any stage. Single and clustered enlarged vacuolated glandular cells. Neutrophilic exudate Actinomycotic colony

ATROPHY Flat monolayer sheets of parabasal cells with preserved

nuclear polarity Parabasal cells may have hyprechromaisa Chromatin uniformly distributed Autolysis result in naked nuclei. Abundant inflammatory exudate.

OUTCOME ASC-US + ASC-H:

*no immediate cancer risk. *most cases don’t progress to cancer. *perform HPV testing +ve----

colposcopy

-ve---repeat PAP smear in 12m

•LSIL: *12-16% cases progress to cancer in 10years *50% cases regress in 2years. *HPV testing +ve-colposcopy LOOP

-ve—repeat PAP smear at 6 and 12m•HSIL:

*20% progress to cancer in 10years.colposcopy

Bethesda system 2001

Specimen type-conventional smear

Specimen adequacy *satisfactory *unsatisfactory General categorisation *NILM *epithelial cell abnormality *other Interpretation

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