1 B C Features to evaluate in Pap smears Section Topic .../96th/pdf/sc21handout.pdf · o...
16
1 ______________________________________________________________________________ T T H H E E P P A A P P S S M M E E A A R R ~ ~ C U R R E N T C R I T E R I A A N D C H A N G I N G C O N C E P T S ~ Rana S. Hoda, M.D., F.I.A.C. 1 Syed A. Hoda, M.D. 2 ~ 1 Medical University of South Carolina, Charleston, SC 2 New York Presbyterian Hospital-Weill Medical College of Cornell University, New York, NY ______________________________________________________________________________ 2 ______________________________________________________________________________ C O N T E N T S ______________________________________________________________________________ Section Topic Page # 1 Basics 03 2 Atrophy 06 3 Repair 09 4 Atypical squamous cells 13 5 Squamous intraepithelial lesion 15 6 Atypical glandular cells 18 7 “Of corn flakes and raisins” 23 8 Glossary 27 9 Key recent references 31 10 Legends: 34 * 2001 Bethesda System and guidelines for management, from JAMA with permission, p44 Each year approximately 50 million women undergo Pap testing in the US. Of these approximately 3.5 million (7%) are diagnosed with a cytological abnormality requiring additional follow-up or re- evaluation. from 2001 Consensus Guidelines, JAMA 2002;287:2120-2129 copyrighted, American Medical Association, reprinted with permission ______________________________________________________________________________ 3 1 B A S I C S ______________________________________________________________________________ Features to evaluate in Pap smears o adequacy o presence of abnormal cells o number and distribution of abnormal cells, and relationship between cells o Cell size, shape o Nuclear size and shape o n:c ratio o nuclear changes and nucleoli o cytoplasmic features o background or diathesis ______________________________________________________________________________ Features of precancerous and cancerous cells o Abnormality in size and shape of cells o Variation in cell size and shape o Increase in nuclear size o Increase in nuclear membrane irregularity o Hyperchromasia o Prominence of nucleoli and irregularity in shape thereof o Thickening of nuclear membrane o Increase in n:c ratio o cytoplasm scanty o Mitosis, increased number and abnormal forms o Non-cohesiveness o Abnomal polarity 4 Epithelial cervical squamous cell types in Pap smear Features superficial cells intermediate parabasal cells cells singly singly singly/sheets loose clustered loose clustered shape polyhedral polyhedral, oval oval, round cell diameter <25um, ~40um ~40um, nucleus <12um, pyknotic <10um, vesicular <6um, vesicular fine chromatin fine chromatin cytoplasm transparent transparent opaque granules - - flat folded, flat flat modified from Koss and Gompel, Introduction to Gynecological Cytopathology, Baltimore, MD, 1999. Comparative size of Pap smear cells ~um 2 Cell type cell area nuclear area Superficial 1500 20 Intermediate 1500 35 Parabasal 300 50 Endocervical 200 50 Endometrial 175 30 Reserve cells 200 50 ______________________________________________________________________________ Causes of false-negative Pap smears o atypical endocervical cells o crowded cell aggregates o cytolysis with isolated large nuclei o intermediate cells with nuclear enlargement o keratinized or metaplastic cells o necrotic debris o smears obscured by blood or inflammation ________________________________________________________________________ 5 Causes of false-positive Pap smears o atrophic smear o atypical endocervical or endometrial cells o multinucleated cells o parakeratosis o perinuclear halo in non-koilocytes o pseudoparakeratosis o repair, squamous metaplasia o tubal metaplasia ______________________________________________________________________________ Minimum number of cells in a Pap smear o conventional 8,000-12.000, well-preserved, well-visualized. o liquid-based 5,000, well-preserved, well-visualized. >10 well-preserved endocervical/squamous metaplastic cells are required for a satisfactory specimen ______________________________________________________________________________ Inflammation obscuring Pap smear cells o partially obscured 50-75% of cells are obscured o unsatisfactory >75% of cells are obscured ______________________________________________________________________________ Iatrogenic changes in Pap smears o chemotherapy o cautery o irritation: IUD, diaphragm, pessary o laser o post-instrumentation: biopsy o radiation therapy ______________________________________________________________________________ Representation of transformation-zone component for specimens determeined by… o At least 10 well-preserved endocervical or squamous metaplastic cells, not necessarily in clusters—TBS 2001 ______________________________________________________________________________ 6 Decidua in Pap smears o abundant pale cytoplasm o bland minute nucleoli (differentiates LSIL) o central round nucleus o polygonal, well-defined cell borders o singly or in small groups o x3 size of neutrophil o only rare cells o pale chromatin o seen in pregnancy or immediately post-partum ______________________________________________________________________________ 2 A T R O P H Y _____________________________________________________________________________ Atrophic vaginitis, findings o blue blobs o cellularity, variable o chromatin, smudgy o debris o nuclei, dot-like, rare bare o polygonal-round cells, slight pleomorphism ______________________________________________________________________________ Differential diagnosis of atrophy o keratinizing dysplasia lower n/c ratio, and refractile dyskeratosis in atrophy o HSIL smudgy nuclei and lack of nuclear detail in atrophy o LSIL uniform nuclei and lack of nuclear detail in atrophy ______________________________________________________________________________ Pap smear changes in pregnancy o Arias-Stella reaction* o Cytotrophoblasts, syncytiotrphoblasts o decidua o glycogenated, folded intermediate “navicular” cells o hematoidin crystals o inflammation
Transcript of 1 B C Features to evaluate in Pap smears Section Topic .../96th/pdf/sc21handout.pdf · o...
1
______________________________________________________________________________
TT HH EE PP AA PP SS MM EE AA RR
~~
C U R R E N T C R I T E R I A A N D
C H A N G I N G C O N C E P T S
~
Rana S. Hoda, M.D., F.I.A.C.1
Syed A. Hoda, M.D.2
~
1 Medical University of South Carolina, Charleston, SC
2 New York Presbyterian Hospital-Weill Medical College of Cornell University, New York, NY
______________________________________________________________________________
2
______________________________________________________________________________
C O N T E N T S
______________________________________________________________________________
Section Topic Page #
1 Basics 03
2 Atrophy 06
3 Repair 09
4 Atypical squamous cells 13
5 Squamous intraepithelial lesion 15
6 Atypical glandular cells 18
7 “Of corn flakes and raisins” 23
8 Glossary 27
9 Key recent references 31
10 Legends: 34
* 2001 Bethesda System and guidelines for management, from JAMA with permission, p44
Each year approximately 50 million women undergo Pap testing in the US. Of these approximately
3.5 million (7%) are diagnosed with a cytological abnormality requiring additional follow-up or re-
evaluation.
from 2001 Consensus Guidelines, JAMA 2002;287:2120-2129
copyrighted, American Medical Association, reprinted with permission
______________________________________________________________________________
3
1 B A S I C S
______________________________________________________________________________
Features to evaluate in Pap smears
o adequacy
o presence of abnormal cells
o number and distribution of abnormal cells, and relationship between cells
o Cell size, shape
o Nuclear size and shape
o n:c ratio
o nuclear changes and nucleoli
o cytoplasmic features
o background or diathesis
______________________________________________________________________________
Features of precancerous and cancerous cells
o Abnormality in size and shape of cells
o Variation in cell size and shape
o Increase in nuclear size
o Increase in nuclear membrane irregularity
o Hyperchromasia
o Prominence of nucleoli and irregularity in shape thereof
o Thickening of nuclear membrane
o Increase in n:c ratio
o cytoplasm scanty
o Mitosis, increased number and abnormal forms
o Non-cohesiveness
o Abnomal polarity
4
Epithelial cervical squamous cell types in Pap smear
Features superficial cells intermediate parabasal cells
cells singly singly singly/sheets
loose clustered loose clustered
shape polyhedral polyhedral, oval oval, round
cell diameter <25um, ~40um ~40um,
nucleus <12um, pyknotic <10um, vesicular <6um, vesicular
fine chromatin fine chromatin
cytoplasm transparent transparent opaque
granules - -
flat folded, flat flat
modified from Koss and Gompel, Introduction to Gynecological Cytopathology, Baltimore, MD, 1999.
Comparative size of Pap smear cells ~um2
Cell type cell area nuclear area
Superficial 1500 20
Intermediate 1500 35
Parabasal 300 50
Endocervical 200 50
Endometrial 175 30
Reserve cells 200 50
______________________________________________________________________________
Causes of false-negative Pap smears
o atypical endocervical cells
o crowded cell aggregates
o cytolysis with isolated large nuclei
o intermediate cells with nuclear enlargement
o keratinized or metaplastic cells
o necrotic debris
o smears obscured by blood or inflammation
________________________________________________________________________
5
Causes of false-positive Pap smears
o atrophic smear
o atypical endocervical or endometrial cells
o multinucleated cells
o parakeratosis
o perinuclear halo in non-koilocytes
o pseudoparakeratosis
o repair, squamous metaplasia
o tubal metaplasia
______________________________________________________________________________
Minimum number of cells in a Pap smear
o conventional 8,000-12.000, well-preserved, well-visualized.
o liquid-based 5,000, well-preserved, well-visualized.
>10 well-preserved endocervical/squamous metaplastic cells are required for a satisfactory specimen
______________________________________________________________________________
Inflammation obscuring Pap smear cells
o partially obscured 50-75% of cells are obscured
o unsatisfactory >75% of cells are obscured
______________________________________________________________________________
Iatrogenic changes in Pap smears
o chemotherapy
o cautery
o irritation: IUD, diaphragm, pessary
o laser
o post-instrumentation: biopsy
o radiation therapy
______________________________________________________________________________
Representation of transformation-zone component for specimens determeined by…
o At least 10 well-preserved endocervical or squamous metaplastic cells, not necessarily in
clusters—TBS 2001
______________________________________________________________________________
6
Decidua in Pap smears
o abundant pale cytoplasm
o bland minute nucleoli (differentiates LSIL)
o central round nucleus
o polygonal, well-defined cell borders
o singly or in small groups
o x3 size of neutrophil
o only rare cells
o pale chromatin
o seen in pregnancy or immediately post-partum
______________________________________________________________________________
2 A T R O P H Y
_____________________________________________________________________________
Atrophic vaginitis, findings
o blue blobs
o cellularity, variable
o chromatin, smudgy
o debris
o nuclei, dot-like, rare bare
o polygonal-round cells, slight pleomorphism
______________________________________________________________________________
Differential diagnosis of atrophy
o keratinizing dysplasia lower n/c ratio, and refractile dyskeratosis in atrophy
o HSIL smudgy nuclei and lack of nuclear detail in atrophy
o LSIL uniform nuclei and lack of nuclear detail in atrophy
______________________________________________________________________________
Pap smear changes in pregnancy
o Arias-Stella reaction*
o Cytotrophoblasts, syncytiotrphoblasts
o decidua
o glycogenated, folded intermediate “navicular” cells
o hematoidin crystals
o inflammation
7
o low estrogen effect: atrophy
o reactive changes
*isolated cells, rarely in clusters, crowded, overlapping nuclei, n/c ratio variable, smudgy chromatin, inflammatory cells
______________________________________________________________________________
Hormonal effect on Pap smears
o atrophic smear: ovarian dysgenesis, Turner’s syndrome, pituitary dysfunction, oophorectomy
o high-estrogen effect: estrogen-producing ovarian tumors,
o variable hormonal patterns: masculinizing tumors, Stein-Levinthal, ovarian dysfunction
______________________________________________________________________________
Small blue cells associated with tamoxifen therapy
o present in 40% of Pap smears in women on tamoxifen
o small, tightly cohesive clusters of cells
o cells have scant to absent cytoplasm
o nuclei are similar to intermediate squamous cells with smooth nuclear membrane
o fine, hyperchromatic chromtin and indisintct, minute nucleoli
o non-neoplastic in nature
o could represent proliferative reserve cells of cervical-vaginal epithelium
o probably result from estrogenic effect of tamoxifen on cervical-vaginal epithelium
______________________________________________________________________________
Atrophy vs small cell ca
Atrophy Small cell ca
large sheets of cells fewer cells
bland nuclei hyperchromatic nuclei
regular shape of nucleus irregular shape
coarse chromatin bland chromatin
no necrosis necrosis
Differential diagnosis of small cells in Pap smears
Tamoxifen cells Endometrial cells Small cell ca Met breast ca
architecture tight clusters tight clusters crowded sheets Indian-file
cells small, bland small, bland small, ovoid small, rounded
nuclei dark , smooth irregular dark, irregular eccentric
nucleoli +/- +, minute (-) +
cytoplasm minimal minimal scanty vacuole
necrosis (-) (-) (+) (-)
mitotic activity (-) (-) (+) (-)
8
Histiocytes in Pap smear
o single cells, variable size
o oval shape
o bean-shaped nucleus, snucleus, may be multinucleated
o large nucleolus
o well-defined cytoplasm, with phagocytized material
o cytoplasmic vacuoles, granular cytoplasm
______________________________________________________________________________
Folic acid deficiency in Pap smear
o may occur in preganancy or upon OC use
o increase cell size, Increase cytoplasm
o increase nuclear size, occasional binucleation
o hyperchromasia
o slightly increased n:c ratio
o chromatin delicate and uniform
______________________________________________________________________________
Predominant cell types at various ages
Age predominant cell type
neonate intermediate (effect of maternal hormones)
pre-pubertal atrophic
pubertal superficial
menstrual intermediate, superficial + blood
pre-ovulation superficial
post-ovulation intermediate
preganancy Intermediate, navicular
post-partum parabasal
post-menopause intermediate or parabasal
9
______________________________________________________________________________
3 R E P A I R & R E G E N E R A T I O N
___________________________________________________________________________
Infections observed on Pap smears, cytological features
Actinomyces long, branching filamentous bacteria-often in tangled clumps “Gupta bodies”
Candida yeasts only (<7um): candida glabrata, yeasts and hyphae: candida albicans
Chlamydia vacuolated cells with targetoid cytoplasmic appearance, inflammation, & repair
CMV characteristic nuclear and cytoplasmic inclusions surrounded by pale halo
Gardnerella seen as “clue” cells, squamous cells covered by small coccobacillary forms
Herpes large, multinucleated, nuclei are ground-glass type, and show molding
HIV no specific changes
Leptothrix long filamentous bacterium, thread-like
Normal flora dominated by rod-shaped, gram (+), blue on Pap stain, lactobacilli
Trichomonas <30u pear shaped protozoa, with red cytoplasmic granules, narrow nucleus
Repair and regeneration, cytological features
o 2-dimensional sheets, single cells rare
o well-defined cell borders
o low n:c ratio,
o slightly enlarged nuclei
o nuclei rounded, smooth nuclear membrane
o fine chromatin
o multiple nucleoli
o mitoses (+)
o abundant cytoplasm
o neutrophils often present
______________________________________________________________________________
Radiation changes in Pap smears
Acute changes
o large cell, with normal n:c ratio
o nuclear membrane irregular
o multinucleation common
o pleomorphism
o dirty background
10
o leukophagocytosis
o smudged nuclear chromatin
o cytoplasmic vacuoles
Chronic changes
o some changes of acute radiation effect persist
o pale smudged nuclei
o low n:c ratio
o biphasic (psychedelic) cytoplasmic staining
o changes of repair and regeneration
Glandular cells, status post-hysterectomy-possible origins:
fistula, vaginal adenosis, endometriosis, prolapsed fallopian tube, supracervical hysterectomy,
glandular metaplasia following radiation or chemotherapy
Obscuring Inflammation
partially obscured by inflammation…
50-75% epithelial cells cannot be visualized—TBS, 2001
unsatisfactory due to inflammation…
>75% epithelial cells cannot be visualized—TBS, 2001
______________________________________________________________________________
Atypical repair
o 3D groups
o slightly dyscohesive
o piling-up of cells
o prominent nucleoli
o irregular chromatin,
o mitosis +
______________________________________________________________________________
Benign parakeratosis
o miniature mature squamous cells
o polygonal
o small, round, pyknotic nuclei
o eosinophilic cytoplasm
11
o associated with reactive, irritative, processes
______________________________________________________________________________
Atypical parakeratosis
o miniature mature squamous cells
o irregular cell shapes
o spindled, elongated, nuclei
o hyperchromatic or pyknotic nuclei
o high n:c ratio
o deeply eosinophilic cytoplasm
o associated with SIL
______________________________________________________________________________
Reactive inflammatory atypia versus dysplasia
atypia due to inflammation dysplasia
cells single/loose clusters same
nucleus regular contour irregular contour
chromatin non-crisp chromatin crisp
cytoplasm may have vacuoles may be denser
cell membrane indistinct cell membrane distinct
background generally exudative generally non-exudative
Reactive inflammatory atypia versus significant glandular atypia
atypia due to inflammation glandular atypia
cells single/sheets single/aggregates
shape of cells variable columnar
nucleus macronucleolus less prominent nucleolus
cytoplasm granular less granular
background generally exudative generally non-exudative
diathesis non-tumoral tumoral
12
Radiation atypia versus SIL
Radiation SIL*
cells single/loose aggregates single/aggregates
size of cells large -
n:c normal increased
nucleus dark, vacuolated hyperchromatic
enlarged, multiple enlarged
cytoplasm vacuolated less granular
*post-radiation SIL shows features of dysplasia: high n:c ratio etc.
Squamous metaplasia versus SIL
Squamous metaplasia SIL
cells flattened isolated
nucleus small larger
<nucleus of intermed cell >nucleus of intermed cell
fine chromatin coarse chromatin
contour: smooth contour: wrinkled, wavy
cytoplasm more less
Characterstic infectious inclusions
o chlamydia variable vacuoles in metaplastic cells
o HPV perinuclear cytoplasmic clearing
o Herpesvirus intranuclear, ground-glass inclusions, haloed
o CMV intranuclear: single, large, round; intracytoplasmic: multiple, small
______________________________________________________________________________
Follicular cervicitis, cytological features
o polymorphous lymphocytes
o tingible body histiocytes
o inflammatory cells
o dirty background
o capillaries traversing lymphoid aggregates
o ~50% of patients have chlamydial infection
13
______________________________________________________________________________
4 A S C : Atypical squamous cells
______________________________________________________________________________
Mimics of ASCUS
o inflammation-associated changes
o parakeratosis
o atrophy
o radiation
o chemotherapy
o deciduas
o multinucleation
o LSIL
o air-drying artifact
o orangeophilia- over-staining artifact
______________________________________________________________________________
HPV-effect, cytological features
o nuclear area >x3 normal intermediate cell nucleus
o increased n:c ratio
o mild hyperchromasia
o slightly darker nucleus with evenly distributed chromatin
o mature cytoplasm
o cave-like cytoplasmic vacuole ~ perinuclear halo
o sharp dense periphery and condensed cytoplasm
______________________________________________________________________________
Definition- ASC-US: Cytological changes that are suggestive of SIL but lack criteria for a definitive
interpretation. The category includes:
~a minority of cases formally classified as ASCUS, favor reactive
~most cases formally classified as ASCUS, NOS or ASCUS, favor SIL
14
Definition- ASC-H: Cytological changes that are suggestive of HSIL but lack criteria for a
definitive interpretation. The association with underlyning CIN2 and CIN3 for ASC-H is lower than
for HSIL, but sufficiently higher than for ASC-US to warrant consideration of different management
recommendations.
______________________________________________________________________________
ASC-H : ASC, cannot exclude high-grade SIL:
o immature small cells
o slightly increased n:c ratio
o mild hyperchromasia
o mild focal nuclear membrane irregularity
o mimics of ASC-H: atrophy, squamous metaplasia
______________________________________________________________________________
“The subjective perception of changes that are intermediate between benign abnormalities and
carcinoma is a potential diagnostic nightmare.”
Koss and Gompel in Introduction to Gynecological Cytopathology
15
______________________________________________________________________________
5 S I L : squamous intraepithelial lesion
LSIL vs. HSIL, cytological features
Abnormality LSIL HSIL
nucleus enlarged + enlarged ++
chromatin granular * coarsely granular
nuclear membrane irregular +/- irregular+
mitosis rare frequent
n:c ratio increased + increased ++
cytoplasm no abnormality** oddly shaped, scanty
koilocytes ++ +
*Opaque in HPV, **perinuclear halo in HPV
______________________________________________________________________________
Mimics of atypical parakeratosis
o degenerative changes
o marked atrophy
______________________________________________________________________________
Keratinizing dysplasia
o markedly increased n:c ratio
o nuclear and cytoplasmic pleomorphism
o nuclei dense and hyperchromatic
o tadpole-like shape
o associated with HSIL or invasive squmaous carcinoma
______________________________________________________________________________
Microinvasive carcinoma on Pap smear
o in general, difficult to diagnose on Pap smears
o cells resemble those of HSIL or invasive carcinoma
o large number of atypical cells
o cells may be present in syncytial arrangement
o presence of nucleoli and parachromatin clearing favor microinvasion
______________________________________________________________________________
16
Invasive squamous cells
o 3D
o dyscohesive
o prominent nucleoli
o abnormal chromatin
o piling-up of cells
o nuclear size variation
o increased n:c ratio
o nucleoli +
o irregular chromatin
o tumor diathesis
______________________________________________________________________________
Cytological features of types of squamous cell neoplasia
Abnormality CIS Microinvasive* Invasive Carcinoma
nucleus enlarged + enlarged + enlarged ++
chromatin irregular - irregular + irregular ++
nucleoli prominent - prominent + prominent ++
diathesis - +/- ++
Cytological features of types of squamous cell carcinoma
Features Keratinizing Nonkeratinizing Small Cell
single cells ++ + +
cell clusters + ++ +
cell Shape Bizarre/spindle Round/polygonal ovoid
cell variance Pleomorphic Uniform Uniform
cytoplasm Orangeophilic Cyanophilic Basophilic
nucleolus +/- ++ +
diathesis +/- ++ +
17
Relative chromatin pattern of various cells seen in Pap smears
Chromatin lesions
Fine, even ASCUS, SIL
Fine, even, clumped SIL
Fine, irregular, nucleoli+ HSIL
Coarse HSIL
Dense and opaque keartiizing SIL, carcinoma
Anogenital HPV
Oncogenic Risk HPV types Associated lesions
low 6, 11, 42-44, 53-55, 62, 66, 70 condyloma, LSIL
intermediate 31, 33, 35, 39, 51, 52, 54, 58, 59, 61, 66-68 LSIL, HSIL, carcinoma
high 16, 18, 45, 56 LSIL, HSIL, carcinoma
______________________________________________________________________________
“Dark cell clusters”
o crowded
o increased n:c ratio
o immature cytoplasm
o anisonucleosis
o mitosis+
o difficult to determine whether squamous or glandular
______________________________________________________________________________
Differential diagnosis of “dark cell clusters”-
o ASC-H,
o HSIL: nuclear membrane irregular
o Atrophy: nuclear membrane smooth
18
Estimated cervical HPV infections and HPV-related disease
Carcinoma 1.5 x 104
HSIL 8-30 x 104
LSIL 1-4 x 106
cytologically normal, HPV+, non-amplified test 8-11 x106
cytologically normal HPV+, PCR test 20-40 x 106
______________________________________________________________________________
6 G L A N D U L A R L E S I O N S
___________________________________________________________________________
Endometrial versus endocervical cells
o endometrial cells packed together, scant cytoplasm
o endocervical cells form looser clusters, more abundant cytoplasm
______________________________________________________________________________
Endometrial stromal cells
o superficial type- resemble histiocytes and form loose aggregates
o deep stromal cells- are round to spindle shaped with small oval nucleus and scant cytoplasm
Reactive vs. neoplastic endocervical cells
feature reactive neoplastic
architecture flat, 2-dimensional microacini, isolated cells or sheets
minimal crowding crowding, papillary
picket fence feathery
nuclei rounded contour oval, variable
anisonucleosis - +/-
anisocytosis rare variable, + in higher grade tumors
nuclear membrane smooth irregular
chromatin fine coarse, hyperchromatic
nucleoli +/-, isolated usually +, prominent, multiple
cytoplasm cyanophilic, syncytial cyanophilic, poorly defined
background clean usually tumor diathesis
cilia + -
mitotic activity - +
apoptosis - +
19
Benign endometrial cells
o small clusters- hyperchromatic crowded groups
o degenerated small cells
o n:c ratio high
o ill-defined border
o single cells uncommon
o nucleus small(=size of intermediate cell nucleus)
o round single nucleoli, small and inconspicuous
o cytoplasm, scant, basophilic and vacuolated
______________________________________________________________________________
Atypical endometrial epithelial cells
o small groups : <10 cells
o slightly enlarged nucleus
o hyperchromatic nucleus
o small nucleoli
o vacuolated cytoplasm
o nuclear atypia > benign reactive or regenerative cells
______________________________________________________________________________
Cytological features of tubal metaplasia
o usually in tissue fragments, Cilia (+)
o palisading of cells, in strips
o cells variable in size
o nuclei round-oval and central
o nucleoli variably present
o cytoplasm variable and pale
______________________________________________________________________________
Cytological features of AIS
o tissue fragments, crowded sheets
o arranged in rosettes, feathery edge, with palisades in gland-like structures
o scant cytoplasm,
o minimally enlarged, round-oval, nuclei that overlap
o granular cytoplasm,
o hyperchromatic nuclei
o slight anisonucleosis
o clean background
20
______________________________________________________________________________
Differential diagnosis of AIS
o oversampling of endocervix,
o endometriosis
o reactive changes, e.g. post-cone, IUD,
o tubal (ciliated cell) metaplasia
o squamous cell carcinoma in situ
o microglandular hyperplasia
o colonic cells in rectovaginal cells
o endometrial cells from lower-uterine segment
o decidua
o reactive changes from prior procedure, eg: cone biopsy
______________________________________________________________________________
Endometrial cells may be seen in…
dysfunctional bleeding, hormonal therapy, IUCD, endometriosis, endometritis, pregnancy, post-
partal state, recent endometrial instrumentation
______________________________________________________________________________
Endometrial cells on Pap smears-
o considered abnormal when…
• shed in post-ovulatory phase
• after menopause, and not on hormone therapy
o considered atypical when…
• nucleus is enlarged (larger than nucleus of intermediate cells)
• nucleoli are conspicuous
______________________________________________________________________________
Atypical endometrial cells seen in…
o endometrial polyp
o endometritis,
o Arias-Stella
o menstrual smear
o hormone therapy in post-menopausal women
o endocervical sampling by brush
21
______________________________________________________________________________
Cytoplasmic features of endocervical adenocarcinoma
o indistinct cell borders
o eosinophilia
o fine distinct granularity
______________________________________________________________________________
Nuclear features of endocervical adenocarcinoma
o well-defined nuclear membrane +++
o round nucleolus +++
o oval nucleus ++
o round nucleus +
o irregular nuclear shape +/-
o multinucleation +/-
______________________________________________________________________________
______________________________________________________________________________
Differential diagnosis of endometrial carcinoma *
o endocervical repair
o endocervical cells under progesterone effect
o endocervical cells with tubal metaplasia
o endometrial cells with papillary syncytial metaplasia
o endometrial hyperplasia
o Arias-Stella reaction
*Pap smear should not be viewed as a method to screen for endometrial carcinoma
______________________________________________________________________________
Endocervical vs. endometrial carcinoma on Pap smears*
Feature endocervical ca endometrial ca
cellularity ++ +
diathesis necrotic watery-diathesis
cell size large, ~190um2 smaller, 140um2
cell shape columnar cuboidal
nuclear size large, ~90um2 smaller, 60um2
22
cytoplasm amphophilic cynaophilic
n:c ratio lower higher
nucleoli ++ +
cells columnar round-oval
cell arrangement 2-dimensional 3-dimensional
papillae ++ -
strips + -
apoptosis + +/-
associated SIL ++ -
Squamous versus glandular carcinoma on Pap smears
squamous ca glandular ca
nucleus pyknotic vesicular
keratin in cytoplasm vacuoles in cytoplasm
“pearl” formation duct formation
tadpole cells papillae
flattened cell aggregates 3-d cell aggregates
crisper cell borders less crisp borders
cells in isolation cells in aggregates
Endocervical vs endometrial carcinoma on Pap smears, differentiating points
o cells from endocervical ca shed more cells than endometrial ca.
o cells from endocervical ca are larger
o nuclei of endocervical ca cells are larger
o cells from endocervical ca are more cyanophilic than cells than endometrial ca.
o cells from endocervical ca more commonly have nucleoli, and are usually larger.
o endometrail ca cells are usually arranged in 3D clusters
o endocervical cells are usually arranged in 2D sheets
o endometrial cells usually have a watery background
o endocervical cells have necrotic diathesis
o apoptosis is more common in endocervical ca
______________________________________________________________________________
23
Glandular cells, status-post hysterectomy, possible origins
o Fistula
o Vaginal adenosis
o Endometriosis
o Prolapsed fallopian tubes
o Supracervical hysterectomy
o Glandular meatplasia following radiation or chemotherapy
______________________________________________________________________________
AIS on thin-layer preparation
o dark cellular groups and sheets with crowding, single cells common
o “continuous” depth of focus
o variability of nuclear size and shape
o stippled chromatin, irregular nuclear membrane
o nucleoli, strips
o feathering
o mitosis
______________________________________________________________________________ ______________________________________________________________________________
7 “ O f c o r n f l a k e s & r a i s i n s ”
______________________________________________________________________________
Cytological appearances in Pap smears simulating common objects
Compared to lesion
o ball-like endometrial carcinoma
o bamboo-like geotrichium
o bean-shaped nucleus of histiocyte
o blue balls menstrual endometrium, contour of endometrial cells
o blue blobs atrophic vaginits
o cannonball aggregates of neutrophils in candida and trichomonas
o cartwheel nuclear chromatin in plasma cells
o cheesy discharge candida vaginitis
o clock-face nuclear chromatin in plasma cells
o clinging diathesis in squamous cell carcinoma on thin-layer preparation
24
o clue cells bacterial vaginosis
o cigar shape nucleus of keratinizing squamous carcinoma
o cocklebur-like hematoidin crystals
o corkscrew Curschmann’s spirals in endocervical mucus
o corn flakes trapped air under
o daisy cell mesothelial hyperplasia in pelvic washings
o dirty background menstrual cycle
o dust ball actinomycetes
o exodus endometrial cells and stroma and histiocytes, days 7-10.
o feathering edges of endocervical carcinoma in situ
o ferning estrogen-effect on mucus
o fiber cells Suggestive of invasive squamous cells
o fibroid cells invasive squamous carcinoma
o fishy smell Gardnerella vaginalis infection, (+) “whiff” test
o ground-glass Nuclei in herpes virus infection
o hair-like leptothrix
o halo HPV
o histiocytic shower exodus, day 5-11 accompanied by endometrial cells
o hobnail AIS of endocervix
o honeycomb endocervical cells
o indian-filing metastatic lobular carcinoma
o india-ink nuclei HGD
o kidney-shaped nucleus of histiocyte
o kite cells HPV effect, soft sign
o koilocytes koilo=hollow or cavity in HPV
o leaf-like squamous metaplasia
o maltese cross refractile starch contaminant
o mosaic-like squamous metaplasia
o moth-eaten trichomoniasis-affected cells
o navicular boat-like (intermediate glycogenated) cells in pregnancy
o oat cell small cell of cervix
o pear Trichomonas vaginalis
o pearl keratinized pearl of squamous cells
o pencil cells endocervical polyp
o permissive cells mature squamous cells that produce HPV virions
25
o pill effect pseudoparakeratosis
o polka-dot cells keratohyaline granules in HPV
o pomegranate herpes virus molded nuclei
o raisin-like HPV-effect
o ratty background cytolysis due to bacteria
o scavenger cells histiocytes in exodus
o school of fish arrangement of regenerative cells
o small blue cells tamoxifen related cells
o smudged cells laser effect, smudging appears in nucleus and cytoplasm
o snake-like elongate nuclei in atypical parakeratosis
o snowshoe alternaria
o sphagetti & meatball candida hyphae and spores
o spider-like metaplastic cells pulled apart
o sticky histiocytes superficial endometrial stromal cells
o strawberry cervicitis colposcopic appearance of trichomonads
o strip formation AIS
o streaming cells in repair
o sulfur granule actinomyces
o tadpole cells nuclei of invasive squamous cells
o targetoid inclusions chlamydia inclusions
o tingible-body follicular cervicitis, macrophage with phagocytic activity
o watery diathesis endometrial carcinoma
o wrinkled cells progesterone effect in intermediate cells
~
contaminants organisms that it may be mistaken for
o contraceptive gels candida spp
o cotton fiber s bacterial colonies
o fibrinous debris leptothrix
o hematoidin nocardia
o mucus leptothix
o sulfonamide crystals lactobacilli
~
References
26
Hoda SA, Hoda RS. “Chewing gum” and “corn flakes”: similies in cytopathology. Diagnostic Cytopathology 1994;10:397. Hoda RS, Hoda SA. “Orphan Annie” nuclei and “strawberry gall bladders”: Modern Pathology 1993;6:637-638. Hoda RS. “Mercury drops” and “spider legs”: Yet more similies in cytopathology. Diagnostic Cytopathology 1995;13:368. Hoda RS, Hoda SA. Yet more analogies in cytopathology. Diagnostic Cytopathol. 2004;30:133 ______________________________________________________________________________
27
______________________________________________________________________________
8 G L O S S A R Y
______________________________________________________________________________
acanthosis thickening of epithelium, a protective hyperplastic phenomenon
acidophilia staining reaction: pink or red with eosin dyes, aka eosinophilia
actinomyces dark filamentous bacteria in clumps, common with IUD use
air-drying artifact limits interpretation, effects nucleus and cytoplasm, usually account
for higher ASCUS rate, air-drying is uncommon in thin-layer preps
alternaria air-borne contaminant, looks like “snow shoes”
amorphous without form or shape
amphophilia cell exhibiting acidophilic and basophilic cytoplasmic staining
anaplasia loss of differentiation, organization and function in tumor cell
anisocytosis notable variation in size or shape of cells
anisokaryosis notable variation in size or shape of nuclei
anucleate squames orangeophilic, large flat squamous (keratinized) cell devoid of nucleus
apoptosis programmed cell death- physiologic or pathologic
atrophic smears smear characterized by dominance of parabasal cells
atypia any deviation from normal cellular morphology
basophilia aka cyanophilia, staining blue or purple with basic dyes
binucleation may be seen with ASCUS or HPV, or various infections
“blue blobs” characteristic of atrophy
brown artifact “corn flakes”, air-trapping under coverslip causing brown cell artifact
brush artifact glandular crowding due to aggressive sampling via endocervix brush
candida albicans a variety of yeast observed in hyphae and conidia
caudate cell tadpole-shaped cells, nucleus in the ‘head’
Chlamydia trachomatis obligatory intracellular bacteria, cytological changes: non-diagnostic;
may be associated with follicular cervicitis
CMV-infected cell uncommon in Pap smears: single large round intranuclear inclusion,
with a thin halo; and small basophilic cytoplasmic inclusions.
“cockle-burrs” hematoidin crystals
“corn flaking” see brown artifact
cyanophilia aka basophilia, staining blue or purple with basic dyes
cytolysis dissolution of cytoplasm, usually with lactobacilli
28
decidual cells endometrial stromal cells with progesterone effect
degenerative changes may be nuclear (e.g. coarse granules) or cytoplasmic (e.g. vacuoles)
differentiation morphological and functional specialization of cell
disordered honeycomb adenocarcinoma in situ of endocervix on thinlayer preparations
Doderlein’s bacilli heterogeneous group of lactobacilli
dyskeratosis keratiniztion of cells below granular layer, premature
dyskaryosis aka dysplasia
dysplasia abnormal alteration of epithelia, characterized by increased primitive
cells associated with variable surface maturation & abnormal
differentiation
eosinophilia property of staining pink or red with eosin dye
epithelial “pearl” concentric structure with keratinized cells, nuclei are retained
estrogenic effect proportion of superficial cells reflect estrogenic effect
“exodus” histiocytes + endometrial epithelial and stromal cluster representing
menstrual smear, common day 4-8 of menstrual cycle
“feathering” characteristic of adenocarcinoma in situ of endocervix
ferning arborizing palm-leaf like pattern of mucus at ovulation
folic acid deficiency cytomegaly, nuclear enlargement; Binucleation, chromatin &
cytoplasm are unchanged
follicular cervicitis numerous lymphocytes and (tingible-body) histiocytes in Pap smear.
glandular grouping usually 3D, poorly defined cell borders
halo see perinuclear halo
herpesvirus-effected cell ground-glass nuclei, multinucleated cells, pomegranate-like molding
histiocyte cell with ill-defined border, finely vacuolated cytoplasm, may have
engulfed material in cytoplasm, nucleus is rounded and reniform,
often eccentrically located
hobnail cell characteristic of clear-cell adenocarcinoma of endometrium
hyperchromatism increase in intensity of nuclear staining, i.e. increased basophilia
hyperkeratosis thickening of the stratum corneum layer of epithelium
hyperplasia increase in number of cells
hypertrophy increase in size of organ or tissue, by increase in size/number of cells
inclusions contents of extraneous or abnormal intrinsic particles within
cytoplasm or nucleus
inflammatory changes reactive changes in cytoplasm (e.g. altered staining) and nucleus (e.g.
blurred chromatin)
29
irradiation effect cytomegaly, karyomegaly, vacuolation of cytoplasma and nucleus,
etc. see Table earlier
karyolysis degenerative change: nucleus swells, loses chromatin and disappears
karyorrhexis nuclear fragmentation
keratinization formation of anucleate squames
koilocytes enlarged superficial or intermediate cells, raisin-like nuclei,
cytoplasm is dense, empty perinuclear cavity with sharp borders,
manifestation of HPV-effect ~ koilos: Greek for cavity
lactobacilli aka Doderlein’s bacilli, thrive in low pH and high glycogen of vagina
leptothrix filamentous microorganism, thrive with trichomonas vaginalis
lubricating jelly may contaminate Pap smears: amorphous material with blue tinge
metaplasia transformation of one mature cell type to another mature cell type
moth-eaten cells in trichomoniasis
multinucleated giant cells could be epithelial, histiocytic, trophoblastic or malignant
multiple nucleoli high-grade carcinoma, glandular repair, glandular neoplasia
navicular cell boat-shaped cell, variant of intermediate cell, seen in pregnancy
necrosis death of tissue, characterized by nuclear changes
nucleolus round-oval intranuclear eosinophilic structure with RNA
nucleus membrane-lined intracytoplasmic body, with chromosomal material
orangeophilia stains orange with OG6 dye
parakeratotic cells miniature superficial squamous cells
pearl concentric structure with keratinized cells, nuclei are retained
perinuclear halo vacuole around nucleus: HPV, trichomonas infection, folic acid def.
phagocytosis presene of particles or fragments within another cell
plasma cell eccentric clock-face nucleus, dense cytoplasm, perinuclear ‘hof’
prominent nucleoli decidua, repair, squamous and glandular dysplasia and neoplasia
pseudokoilocytosis may be due to glycogen content of cell, or inflammation
pseudoparakeratosis glandular cells with orangeophilic cytoplasm with hormonal therapy,
aka pill effect
psammoma bodies may indicate papillary ovarian tumors, or mesothelial hyperplasia, etc
pyknosis nuclear shrinkage, condensation of chromatin to structureless mass
repair sheets or syncytial of cells, with nuclear enlargement, prominent
nucleoli, chromatin remains even; mitosis are seen, but are normal
sheets cell aggregate: monolayer, regularly arranged, distinct cell boundaries
sperm in Pap smear In smears from HIV-infected, indicative of unprotected intercourse
30
spindle cells rule out pleomorphic dysplasia and keratinizing squmaous carcinoma
syncytium irregularly arranged cells with indistinct cell boundaries
torulopsis glabrata may be symptomatic, difficult to distinguish from candida on Pap
transformation zone most SIL arise in the transformation zone—an area of variable size
and extent wherein squamous metaplasia occurs. The t-zone recedes
with age and may lie within endocervical canal in older women
trichomonas vaginalis ovoid protozoan, indistinct nucleus, cytoplasmic granules present
trophoblastic cells syncytial: 20+ nuclei, amphophilic cytoplasm, uniformly coarse
irregular chromatin, nucleoli rare
cytotrophoblast: large cell, nucleus large and irregular, uniformly
amphophilic cytoplasm, nucleus lobulated may be vacuolated
tubal metaplasia metaplastic process of endocervix, with tubal-type epithelium, more
common in women aged: 35+, aka ‘ciliated cell’ metaplasia
undifferentiated cells cell lacking differentiation, organization or specialization
vacuole intracytoplasmic or intranuclear clear space with a sharp outline—in
IUD use, radiation, glycogen, glandular neoplasia
vaginal adenosis glandular epithelium in vagina, usually follows DES exposure in utero
vesicular uniformly delicate nuclear chromatin
“watery” diathesis usually seen in endometrial carcinoma
______________________________________________________________________________
Acknowledgements: Information in this material has been derived from references listed above and from the following textbooks.
o Bibbo, Comprehensive Cytopathology, Philadephia, Saunders, 1997
o DeMay, Practical Principles of Cytopathology, Chicago, ASCP, 1999
o Ducatman and Wang, The Pap Smear, New York, Oxford, 2002
o Koss and Gompel, Introduction to Gynecological Cytopathology, Baltimore, W&W, 1998
o Mckee, Diagnostic Cytopathology, Edinburgh, Elsevier, 2003
o Ramzy, Clinical Cytopathology & Aspiration Biopsy, Appleton and Lange, 2000
o Solomon and Nayar, The Bethesda System, 2nd ed, New York, Springer, 2003
o Gray and Mckee, Diagnostic Cytopathology, Elsevier, 2003
o Geisinger, Stanley, Raab, Silverman, Abati, Modern Cytopathology, Phila, Churchill-Living., 2004
___________________________________________________________________________
______________________________________________________________________________
31
9 R E C E N T K E Y R E F E R E N C E S
______________________________________________________________________________
-Acs G, Gupta PK, Baloch ZW. Glandular and squamous atypia and intraepithelial lesions in atrophic
cervicovaginal smears. Acta Cytol. 2000;44:611-7.
-al-Nafussi A, Rebello G, al-Yusif R, et al. The borderline cervical smear: colposcopic and biopsy outcome. J
Clin Pathol. 2000;53:439-44.
-Baker JJ. Conventional and liquid-based cervicovaginal cytology: A comparison study with clinical and
histologic follow-up. Diagn Cytopathol. 2002;27:185-8.
-Bergeron C, Bishop J, Lemarie A, et al. Accuracy of thin-layer cytology in patients undergoing cervical cone
biopsy. Acta Cytol. 2001;45:519-24.
-Biscotti CV, O'Brien DL, Gero MA, et al. Thin-layer Pap test vs. conventional Pap smear. Analysis of 400 split
samples. J Reprod Med. 2002;47:9-13.
-Brogi E, Tambouret R, Bell DA. Classification of benign endometrial glandular cells in cervical smears from
postmenopausal women. Cancer. 2002;96:60-6.
-Bulten J, de Wilde PC, Boonstra H, et al. Proliferation in "atypical" atrophic pap smears. Gynecol Oncol.
2000;79:225-9.
-Cenci M, Vecchione A. Atypical squamous and glandular cells of undetermined significance (ASCUS and
AGUS) of the uterine cervix. Anticancer Res. 2000;20:3701-7.
-Chhieng DC, Elgert P, Cohen JM, et al. Clinical implications of atypical glandular cells of undetermined
significance, favor endometrial origin. Cancer. 2001;93:351-6.
-DeMay RM. Hyperchromatic crowded groups: pitfalls in pap smear diagnosis. Am J Clin Pathol. 2000;114
Suppl:S36-43.
-DeMay RM. Should we abandon Pap smear testing? Am J Clin Pathol. 2000;114 Suppl:S48-51.
-DeMay RM. Hyperchromatic crowded groups: pitfalls in pap smear diagnosis. Am J Clin Pathol. 2000;114
Suppl:S36-43.
-Finan RR, Irani-Hakime N, Tamim H, et al. Detection of human papillomavirus (HPV) genotypes in cervico-
vaginal scrapes of women with normal and abnormal cytology. Clin Microbiol Infect. 2001;7:688-92.
-Hecht JL, Sheets EE, Lee KR. Atypical glandular cells of undetermined significance in conventional
cervical/vaginal smears and thin-layer preparations. Cancer. 2002;25;96:1-4.
-Keating JT, Wang HH. Significance of a diagnosis of atypical squamous cells of undetermined significance for
Papanicolaou smears in perimenopausal and postmenopausal women. Cancer. 2001;93:100-5.
-Luzzatto R, Poli M, Recktenvald M, et al. Human papillomavirus infection in atrophic smears. A case report.
Acta Cytol. 2000;44:420-2.
-Llewellyn H. Observer variation, dysplasia grading, and HPV typing: a review. Am J Clin Pathol. 2000;114
Suppl:S21-35.
-O'Meara A. Present standards for cervical cancer screening. Curr Opin Oncol. 2002;14:505-11.
Smith JH. Bethesda 2001.Cytopathology. 2002;13:4-10.
32
-Solomon D, Davey D, Kurman R, et al. The 2001 Bethesda System: terminology for reporting results of
cervical cytology. JAMA. 2002;287:2114-9.
-Migliore G, Rossi E, Aldovini A, et al. Variation in the assessment of adequacy in cervical smears. Cytopathology.
2001;12:377-82.
-Smith-McCune K, Mancuso V, Contant T, et al. Management of women with atypical Papanicolaou tests of
undetermined significance by board-certified gynecologists: discrepancies with published guidelines. Am J Obstet
Gynecol. 2001;185:551-6.
-Shin CH, Schorge JO, Lee KR, et al. Cytologic and biopsy findings leading to conization in adenocarcinoma in
situ of the cervix. Obstet Gynecol. 2002;100:271-6.
-Levine PH, Waisman J, Mittal K. Significance of the cytologic diagnosis of endocervical glandular involvement
inhigh-grade squamous intraepithelial lesions. Diagn Cytopathol. 2002;26:217-21.
-Mathers ME, Johnson SJ, Wadehra V. How predictive is a cervical smear suggesting glandular neoplasia?
Cytopathology. 2002;13:83-91.
-Nasuti JF, Fleisher SR, Gupta PK. Atypical glandular cells of undetermined significance (AGUS): clinical
considerations and cytohistologic correlation. Diagn Cytopathol. 2002;26:186-90.
-Selvaggi SM, Guidos BJ. Endocervical component: is it a determinant of specimen adequacy? Diagn Cytopathol.
2002;26:53-5.
-Sherman ME, Solomon D, Schiffman M. Qualification of ASCUS. A comparison of equivocal LSIL and
equivocal HSIL cervical cytology in the ASCUS LSIL Triage Study. Am J Clin Pathol. 2001;116:386-94.
-Solomon D, Schiffman M, Tarone R. ASCUS LSIL Triage Study (ALTS) conclusions reaffirmed: response to a
November2001 commentary. Obstet Gynecol. 2002;99:671-4.
-Solomon D, Davey D, Kurman R,et al. The 2001 Bethesda System: terminology for reporting results of
cervical cytology. JAMA. 2002;24;287:2114-9.
-Solomon D, Schiffman M, Tarone R. ASCUS LSIL Triage Study (ALTS) conclusions reaffirmed: response to a
November 2001 commentary. Obstet Gynecol. 2002;99:671-4.
-van der Laak JA, de Bie LM, de Leeuw H, et al. The effect of Replens on vaginal cytology in the treatment of
postmenopausal atrophy: cytomorphology versus computerised cytometry. J Clin Pathol. 2002;55:446-51.
-Wang N, Emancipator SN, Rose P, et al. Histologic follow-up of atypical endocervical cells. Liquid-based,
thin-layerpreparation vs. conventional Pap smear. Acta Cytol. 2002;46:453-7.
-Wu HH, Schuetz MJ 3rd, Cramer H. Significance of benign endometrial cells in Pap smears from
postmenopausal women. J Reprod Med. 2001;46:795-8.
-Yang YJ, Trapkin LK, Demoski RK, et al. The small blue cell dilemma associated with tamoxifen therapy.
Arch Pathol Lab Med. 2001;125:1047-50.
-Zardawi IM, Rode JW. Clinical value of repeat Pap smear at the time of colposcopy. Acta Cytol. 2002;46:495-8.
*
-Simsir A, Hwang S, Cangiarella J, Elgert P, Levine P, Sheffield MV, Roberson J, Talley L, Chhieng DC.
Glandular cell atypia on Papanicolaou smears: interobserver variability in the diagnosis and prediction of cell of
origin. Cancer. 2003;99:323-30.
33
Klinkhamer PJ, Meerding WJ, Rosier PF, Hanselaar AG. Liquid-based cervical cytology.
Cancer. 2003;99:263-71. Review.
-Cox JT; American Society for Colposcopy and Cervical Pathology. The clinician's view: role of human
papillomavirus testing in the American Society for Colposcopy and Cervical Pathology Guidelines for the
management of abnormal cervical cytology and cervical cancer precursors. Arch Pathol Lab Med. 2003;127:950.
-Papanicolau Society of Cytopathology Practice Guidelines Task Force. Papanicolaou Society of
Cytopathology guidelines for educational notes, disclaimers, and similar comments on reports of cervical
cytology specimens. Diagn Cytopathol. 2003;28:282-5.
-Martin-Hirsch PL, Koliopoulos G, Paraskevaidis E. Is it now time to evaluate the true accuracy of cervical
cytology screening? A review of the literature. Eur J Gynaecol Oncol. 2002;23:363-5.
-Nygard JF, Sauer T, Skjeldestad FE, Skare GB, Thoresen SO. CIN 2/3 and cervical cancer after an ASCUS
pap smear. A 7-year, prospective study of the Norwegian population-based, coordinated screening program.
Acta Cytol. 2003;47:991-1000.
-Zardawi IM. Cellularity of liquid-based, thin-layer cervical cytology. Acta Cytol. 2003;47:943.
-Williamson BA, DeFrias D, Gunn R, Tarjan G, Nayar R. Significance of extensive hyperkeratosis on
cervical/vaginal smears. Acta Cytol. 2003;47:749-52.
-Okuyama T, Maeda S, Kobayashi TK, Takahashi R. Detection of Trichomonas vaginalis by combined A6p
and P65 sequences using PCR amplification from Papanicolaou-stained smears. Acta Cytol. 2003;47:696-8.
-Pientong C, Ekalaksananan T, Swadpanich U, Kongyingyoes B, Kritpetcharat O, Yuenyao P, Ruckait N.
Immunocytochemical detection of p16INK4a protein in scraped cervical cells. Acta Cytol. 2003;47:616-23.
-Studeman KD, Ioffe OB, Puszkiewicz J, Sauvegeot J, Henry MR. Effect of cellularity on the sensitivity of
detecting squamous lesions in liquid-based cervical cytology. Acta Cytol. 2003;47:605-10.
-Payandeh F, Koss LG. Nuclear grooves in normal and abnormal cervical smears.
Acta Cytol. 2003;47:421-5.
-Mattosinho de Castro Ferraz Mda G, Focchi J, Stavale JN, Nicolau SM, Rodrigues de Lima G, Baracat EC.
Atypical glandular cells of undetermined significance. Cytologic predictive value for glandular involvement in
high grade squamous intraepithelial lesions. Acta Cytol. 2003;47:154-8.
-Demirezen S. Review of cytologic criteria of bacterial vaginosis: examination of 2,841 Papanicolaou-stained
vaginal smears. Diagn Cytopathol. 2003;29:156-9.
______________________________________________________________________________
34
______________________________________________________________________________
1 0 L E G E N D S
______________________________________________________________________________
Legends to CD-ROM Images
1 Normal squamous cells in Pap smear: Superficial cells are flattened, have abundant
cytoplasm and pyknotic nuclei. Intermediate cells are folded, have less abundant cytoplasm
and vesicular nuclei (thin-layer; Papanicolaou stain; 400X).
2 Normal endocervical cells appear en face as flattened honeycombed sheets of cells with
finely vacuolated cytoplasm, round nuclei and small nucleoli. On-edge (inset) the cells are
columnar with basal ovoid nuclei (thin-layer; Papanicolaou stain; 400X).
3 Squamous metaplasia: small parabasal-type cells with variable shape, distinct cell borders,
and rounded regular nuclei (thin-layer; Papanicolaou stain; 400X)
4 Normal endometrial cells: epithelial cells of endometrium are usually in a 3-dimensional
cluster. Nuclear size is comparable to intermediate cell nuclei, and cytoplasm is scant (thin-
layer; Papanicolaou stain; 400X).
5 Lactobacilli induce cytolysis. Cytolytic changes in intermediate cells are typically due to
peptolytic influences of Lactobacilli. Note the “free” nuclei, cellular debris, and rod-like
bacilli (thin-layer; Papanicolaou stain; 400X).
6 Coccobacilli: partial obliteration of epithelial cells by small bacilli gives the cells a grainy,
velvety (clue cell) appearance (thin-layer; Papanicolaou stain; 400X).
7 Candida spp: filamentous structures with pseudohyphae and spore forms (conventional
smear; Papanicolaou stain; 400X).
8 Leptothrix with trichomonas vaginalis: Leptothrix are thin, curved filamentous organisms
commonly found with trichomonas (conventional smear; Papanicolaou stain; 400X).
9 Trichomonas vaginalis: pear-shaped organisms with an eccentric faint nucleus and
cytoplasmic granules (thin-layer; Papanicolaou stain; 400X).
10 Herpes simplex virus: multinucleate giant cell with homogenous, “ground-glass”
appearance of nuclei with margination of chromatin. Note nuclear molding (thin-layer;
Papanicolaou stain; 400X).
35
11 Actinomyces organisms occur as aggregates of filamentous, branching bacteria radiating
from the darker center, usually seen with IUD use (conventional smear; Papanicolaou stain;
400X).
12 Squamous cells with repair are arranged in flat cohesive 2-dimesional sheets.
Nuclear/cytoplasmic ratio is low. Nuclei show “streaming” with prominent nucleoli. Note
intracellular neutrophils. Cytoplasm is usually cyanophilic (thin-layer; Papanicolaou stain;
400X).
13 Reactive endocervical cells are arranged in a honeycombed manner without cellular
overlap. Cells are have rounded with hyperchromatic nuclei and prominent nucleoli (thin-
layer; Papanicolaou stain; 400X).
14 Radiation change show enlarged cells with large nuclei and prominent nucleoli. Cytoplasm
is vacuolated (conventional smear; Papanicolaou stain; 400X).
15 IUD cell are endometrial cells shed in a patient with intrauterine contraceptive device in
place. These cells appear singly with high n:c ratio. Cytoplasm is finely vacuolated
(conventional smear; Papanicolaou stain; 400X).
16 Endometriosis: Endometrial glandular and stromal cells in a patient with cervicovaginal
endometriosis. Hemosiderin-laden macrophages may also be seen (thin-layer; Papanicolaou
stain; 400X).
17 Menstrual endometrium “exodus”: This cluster of endometrial cells is seen towards the
end of menstruation and comprise of glandular cells (at periphery) and stromal cells (at
center) (conventional smear; Papanicolaou stain; 400X).
18 Atrophy: Sheets of parabasal cells with enlarged nuclei and bland smudgy chromatin.
Background shows air-drying, inflammatory cells and mummified parabasal cells “blue
blobs” (conventional smear; Papanicolaou stain; 400X).
19 Atrophic vaginitis: Advanced atrophy commonly shows parabasal cells associated with
inflammatory cells (thin-layer; Papanicolaou stain; 400X).
20 Follicular cervicitis: Numerous lymphocytes derived from lymphoid follicle in cervix.
Note macrophages with phagocytic activity (“tingible body” macrophage) (conventional
smear; Papanicolaou stain; 400X).
21 Hyperkeratosis is a mucosal surface reaction characterized by anucleate squames and
occurs in response to irritation (thin-layer; Papanicolaou stain; 400X).
22 Parakeratosis is another mucosal surface reaction characterized by presence of miniature
squamous cells. These cells exfoliate either singly or in aggregates (thin-layer; Papanicolaou
stain; 400X).
36
23 Tubal metaplasia is ciliated columnar endocervical cells that originate from upper
endocervical canal (conventional smear; Papanicolaou stain; 400X).
24 Endocervical polyp: usually shows up in Pap smears as numerous columnar endocervical
cells with tubal metaplasia. Nuclear atypia is minimal (conventional smear; Papanicolaou
stain; 400X).
25 Syncytiotrophoblast is a large multinucleated cell and may be seen after an aborted
pregnancy (conventional smear; Papanicolaou stain; 400X).
26 Atypical squamous cells of undetermined significance (ASC-US): Mature cells with
moderately enlarged nuclei, minimal hyperchromasia, and smooth nuclear membranes.
Binucleation may be seen (thin-layer; Papanicolaou stain; 400X).
27 Low-grade squamous intraepithelial lesion (HPV effect): Mature squamous cells with
classic human papillomavirus cytopathic effects- enlarged hyperchromatic, nuclei with
irregular nuclear envelop. Binucleation is common. Cytoplasm has a sharply demarcated
perinuclear halo (thin-layer; Papanicolaou stain; 400).
28 Low-grade squamous intraepithelial lesion (mild dysplasia): Nuclei are enlarged,
hyperchromatic with mild nuclear membrane irregularity. The cells have “mature”
cytoplasm (thin-layer, Papanicolaou stain; 400X).
29 Low-grade squamous intraepithelial lesion (mild dysplasia): Nuclei are enlarged,
hyperchromatic with mild nuclear membrane irregularity. The cells have “mature”
cytoplasm (conventional smear, Papanicolaou stain; 400X).
30 Atypical squamous cells, cannot exclude HSIL (ASC-H): These atypical cells are of
squamous metaplastic type. Nuclei are enlarged with membrane irregularity and finely
granular chromatin. The n:c ratio is not as high as HSIL (thin-layer; Papanicolaou stain;
400X).
31 High-grade squamous intraepithelial lesion (HSIL): Cells show high n:c ratio and
enlarged, hyperchromatic nuclei with marked nuclear membrane irregularity (thin-layer,
Papanicolaou stain; 400X).
32 High-grade squamous intraepithelial lesion (HSIL): Cells show high n:c ratio and
enlarged, hyperchromatic nuclei with marked nuclear membrane irregularity (thin-layer,
Papanicolaou stain; 400X).
33 HSIL (CIN 3/CIS) involving endocervical glands: Large syncytial aggregate (ill-defined
cell borders). Note loss of nuclear polarity (thin-layer; Papanicolaou stain; 400X).
34 Atypical parakeratosis: Sheet of elongated miniature squamous cells with atypical nuclei.
Cytoplasm is eosinophilic to orangeophilic. Parakeratosis may be associated with LSIL
(thin-layer; Papanicolaou stain; 400X).
37
35 Keratinizing dysplasia: High-grade keratinizing dysplasia showing both nuclear and
cytoplasmic pleomorphism. Note orange cytoplasm and large, hyperchromatic nuclei (thin-
layer; Papanicolaou stain; 400X).
36 Keratinizing squamous cell carcinoma: Dispersed cells of spindle to elongated and
caudate forms with heavily keratinized cytoplasm. Nuclei are pleomorphic and
hyperchromatic. Nucleoli are less conspicuous than the non-keratinizing type. These
tumors generally lack tumor diathesis (conventional smear; Papanicolaou stain; 400X).
37 Non-keratinizing squamous cell carcinoma: Malignant polygonal cells are arranged in
either loose clusters or crowded groups or singly. Nuclei are large, mostly round, and have
coarse chromatin, and macronucleoli. Cytoplasm is dense with distinct cell borders. N:C
ratio is moderate. Tumor diathesis is generally present (thin-layer; Papanicolaou stain;
400X).
38 Atypical glandular cells with pseudostratification. These cells may be of endocervical or
endometrial in origin. Nuclei show minimal atypia. Differential diagnosis includes tubal
metaplasia or glandular neoplasia (thin-layer, Papanicolaou stain; 400X).
39 Atypical endocervical cells with focal palisade arrangement (“feathering”), and enlarged
hyperchromatic nuclei with small nucleoli (thin-layer; Papanicolaou stain; 400X).
40 Atypical endometrial cells in a 3-dimensional cluster. Nuclei are hyperchromatic with
prominent nucleoli. (thin-layer; Papanicolaou stain; 400X).
41 Atypical endocervical cells-favor neoplastic: A dense cluster of endocervical cells with
peripheral palisading and large hyperchromatic nuclei (thin-layer; Papanicolaou stain; 400X).
42 Atypical glandular cells- favor neoplastic: Strip of cells with large hyperchromatic nuclei.
Nucleoli are not conspicuous (thin-layer; Papanicolaou stain; 400X).
43 Endocervical adenocarcinoma in situ seen as a cluster of hyperchromatic crowded group
of cells with high n:c ratio and prominent nuclear protrusion. Nuclei are large, elongated
and oval with coarse chromatin. Nucleoli are lacking. Background is clean. Inset shows a
group of pesudostratified cells (thin-layer; Papanicolaou stain; 400X).
44 Endocervical adenocarcinoma: Well differentiated endocervical adenocarcinoma showing
large group of cells in a predominantly 2-dimensional group. Cells show high n:c ratio,
enlarged hyperchromatic nuclei and macronucleoli amid necrotic diathesis. Inset shows a
rosette (conventional smear; Papanicolaou stain; 400X).
45 Endometrial adenocarcinoma seen as a papillary tuft of malignant cells from a case of
papillary serous variant. The malignant cells show nuclear enlargement and pleomorphism
(thin-layer; Papanicolaou stain; 400X).
38
46 Endometrial adenocarcinoma is seen as round cells with cyanophilic and vacuolated
cytoplasm with intracytoplasmic neutrophils. Background shows the characteristic blue-
tinged, finely granular “watery” diathesis {thin-layer (left) and conventional smear (right);
Papanicolaou stain; 400X}.
47 Atypical histiocytes in endometrial adenocarcinoma: Large loosely structured cluster of
cells with intracytoplasmic vacuoles containing numerous neutrophils. (conventional smear;
Papanicolaou stain; 400X).
48 Small cell anaplastic carcinoma of cervix shows tight syncytial aggregate of small
irregular tumor cells. Note scant cytoplasm and small nuclei. There is nuclear molding
(thin-layer preparation; Papanicolaou stain; 400X).
49 Metastatic lobular carcinoma of breast shows a cluster of small cells with large irregular
nuclei and scant cytoplasm. A clean background of the smear is often observed in metastatic
tumors. Clinical history is important (thin-layer preparation; Papanicolaou stain; 400X).
50 Acknowledgements.
Contrary to popular belief, the purpose of the Pap smear is to screen for cervical cancer, not to
diagnose them. Wang and Ducatman, in The Pap Smear
Supplement
Attached papers have been reproduced from JAMA with permission
Journal name Year Citation Items used
JAMA 2002 287;2114-19 full text
JAMA 2002 287:2120-20 full text
Rights granted herein are non-exclusive and limited to one-time only reproduction in rinted format in
the English language. Your credit line must include the name of the publication, issue date, volume
and page number, as well as “copyrighted (year of publication), American Medical Association.
US&CAP short course
Pap smear:current criteria & changing concepts
Hoda & Hoda
normal squamous cells
1
superficial cell
intermediate cell
normal endocervical cells
2 3
squamous metaplastic cells
4
normal endometrial cells
5
lactobacilli inducing cytolysis
6
coccobacilli ~ bacterial vaginosis
7
candida spp
leptothrix and trichomonas vaginalis
8
trichomonas vaginalis
leptothrix
9
trichomonas vaginalis
10
herpes simplex virus
11
actinomyces spp
12
squamous cells with repair
13
reactive endocervical cells
14
radiation changes
15
IUD cell
16
vaginal endometriosis
17
menstrual endometrium ‘exodus’
atrophy
18
blue blob
atrophic vaginitis
19
parabasal cell
follicular cervicitis
20
tingible body macrophage
21
hyperkeratosis
22
parakeratosistubal metaplasia
23
cilia
endocervical polyp
24 25
syncytiotrophoblast
atypical squamous cells of undetermined significance, ASCUS
26
low grade squamous intraepithelial lesion, LSIL
27
LSIL
28
LSIL
29
30
atypical squamous cells cannot exclude HSIL, ASC-H high grade squamous intraepithelial lesion, HSIL
31
HSIL
32 33
HSIL involving endocervical glands
34
atypical parakeratosis
35
keratinizing dysplasia
keratinizing squamous ca
36
non-keratinizing squamous ca
37
38
atypical glandular cells
39
atypical endocervical cells
atypical endometrial cells
40
atypical endocervical cells, favor neoplastic
41
atypical glandular cells, favor neoplastic
42
endocervical adenocarcinoma in situ - AIS
43
endocervical adenoca
44 45
endometrial adenoca
endometrial adenoca
46Watery diathesis 47
atypical histiocytes in endometrial adenoca
48
small cell anaplastic ca of cervix
49
metastatic lobular breast ca
US&CAP short coursePap smear : current criteria & changing concepts
Hoda & Hoda
Mr James Nicholson, Ms Patricia Houser & Dr Sachiko MinamiguchiPathology, Medical University of South Carolina, Charleston, SC contributed invaluable time & effort in preparing these images
![The E4 Protein - National Institutes of Health · E4 is located in the cytoplasm for the most part, however intranuclear and perinuclear inclusions have been observed [14,29]. Mutations](https://static.fdocuments.us/doc/165x107/601bf19597ecd3610f3827ee/the-e4-protein-national-institutes-of-health-e4-is-located-in-the-cytoplasm-for.jpg)
