Benign Non- Inflammatory Conditions of the Cervix

ML 301 Cytology Dr Pritinesh Singh

Department of PathologySchool of Health Sciences

Fiji School of Medicine

Objectives

Know the cytology of benign non -inflammatory conditions affecting the pap smearAppreciate and classify the different benign non- inflammatory conditions causing cellular changes in the cervical pap smear

Review

Basal cellsParabasal cellsIntermediate cellsSuperficial cells

Atrophy

Pap smear is dominated by basal/ parabasal cellsCommon in late postmenopausal period, the postpartum period & during childhoodSyncytial sheets of basal and parabasalcells are characteristic of atrophy

Atrophy

Spindle parabasal cells are also common (transitional metaplasia)Can also be associated with nuclear enlargement into the range seen in dysplasia accompanied by mild hyperchromasiaAir-drying is common in atrophic smears & contributes to nuclear enlargement however nuclear membranes are uniform and chromatin is bland (smudgy)

Atrophy

AtrophyAlso commonly associated with evidence of inflammationSuch as evidence of

cellular degeneration, including numerous naked nucleinuclear pyknosispseudokeratinizationabundant inflammation

Atrophy

A granular basophilic background in which blue blobs (mummified parabasal cells) may be identified.

Benign Proliferative Reactions

Includes:

Squamous metaplasiaImmature - mature

KeratosisHyperkeratosis & parakeratosis

Squamous Metaplasia

Begins with reserve cell having the unique ability to differentiate into either a glandular or a squamous cellEarliest change is known as RCH (reserve cell hyperplasia)

Proliferation of undifferentiated reserve cells underneath the endocervical glandular epitheliumRarely recognized in pap smear

Squamous Metaplasia

Following RCH the cells start acquiring squamous features (beginning of true squamousmetaplasia.This immature form is commonly recognized in pap smears

It’s para-basal sized with rounded cell borders, that are sharply defined.Form loosely aggregated flat sheets in a characteristic cobblestone patternCytoplasm is thick and dense

Metaplasia

Immature metaplasia differentiates to mature squamous metaplasiacharacterized by immature sized cells that are eventually indistinguishable from native squamous cells

Squamous Metaplasia

A and B: mature squamous metaplasia. C: immature squamous metaplasia. D: immature squamousmetaplasia with pattern of transitional metaplasia.

KeratosisOccurs in response to severe stress or irritation such as a pessary or uterine prolapse

Normal nonkeratinizing epithelium hyper-differentiates into two additional cell layers at the surface

a granular layer – characterized by superficial cells with dark keratohyaline granules in the cytoplasmA stratum cornuem – characterized by anucleatesquames (diagnostic of hyperkeratosis)

Hyperkeratosis

Keratosis

Parakeratosis- another surface keratoticreaction characterized by presence of miniature superficial cells in the pap smear which can be seen as single cells, layered strips or pearlsAlthough these keratotic conditions are benign they could mask an underlying squamous abnormality, possibly including cancer

Parakeratosis

Pearl appearance of parakeratosis

ParakeratosisSingle cell

Benign Cellular Changes

Distinguishing inflammatory changes from dysplasia is a common everyday problem in cytologyEssential difference between inflammatory atypia and dysplasia is the nucleus

If its dark and big, it’s dyplasia!

Radiation Effect

Characterized by presence of macrocytes ie cytomegalic cells with enlarged or multiple nuclei & voluminous cytoplasm but relatively normal NC ratioNuclei range from pale – hyperchromatic(but smudgy) and may be vacuolated.Cytoplasm often stains pink & blue (polychromasia) and also may be vacuolated

Radiation Effect

Cytoplasmic vacuoles may contain leukocytesFrequently accompanied by repair/regeneration May regress after therapy or persist for lifeMacrocytes can also occur in condyloma & Vit. Deficiency (folate, B12)

Enlarged nuclei with abundant polychromatic cytoplasm with vacuolization. Mild nuclear hyperchromasia without coarse chromatin, prominent nucleoli (coexisting repair). Note multinucleation (upper right corner insert).

Nuclear and cytoplasmic enlargement, smooth nuclear outlines with mild hyperchromasia but chromatin is finely granular. Cytoplasmic polychromasia and vacuolization

Multinucleated cell. Abundant polychromatic cytoplasm; cytoplasmic vacuoles.

Post-radiation Dysplasia

Serious lesion that sometimes develop after radiation therapy, usually for squamous cell carcinomaIt is probably more closely related to ionizing radiation then to HPVPatients who develop this lesion are at high risk of recurrence particularly if it occurs within 3 yrs of therapy.

Changes include: cytomegaly, increased NC ratio, oval/irregular hyperchromatic nucleusFine/ coarse granular chromatinEosinophilic / amphophilic cytoplasm

Post-radiation Dysplasia

Self Assessment Questions

When should atrophic cells be seen?What are some errors in preparing & processing a papsmear that may give rise to an atrophic smear?What are some characteristic features of atrophic pap smears?

What is squamous metaplasia?How is squamous metaplasia identified on pap smears?What is keratosis?What are the subtypes of keratosis and how are they identified on papsmears?How can radiation changes be distinguisedin a pap smear?

Self Assessment Questions