Lectures
Week 1
Wednesday, 1-3 PM
- Content Expert: David C. Wilbur, MD
- Cytotechnologist: Heather Smith
- Objective: The objective of this study set is to train residents and fellows about basic Benign GYN cytology and Squamous Abnormalities seen in a Pap smear
- Outline: Dr. Wilbur Normal Cytology Lecture
Specimen Adequacy
- Satisfactory for Evaluation
- Describe the presence/absence of TZ component and any other quality indicators (partially obscuring blood, inflammation, etc)
- Unsatisfactory for Evaluation
- Specimen rejected/not processed (not labeled, broken slide, etc)
- Specimen processed and examined but unsat for evaluation b/c of lack of squamous component, or if more than 75% of squamous cells are obscured
If abnormal cells are seen, regardless, the smear is automatically satisfactory for evaluation
Squamous cells (4 types)
Parabasal Cells – MG5-39366 and MG9-31243
- Indicates that the epithelium is “poorly differentiated”, ie atrophic
- Common finding during early childhood, postmenopausal, post partum
- Cells have dense cytoplasm, centrally located round nucleus
- In atrophic patients, sheets of atrophic parabasal cells often appear in syncytial
Intermediate Cells – MG05-45463
- Parabasal cells begin to flatten and mature into intermediate cells
- Cytoplasm changes from thick with rounded outlines to thin with polygonal outlines
- Nucleus is centrally placed and is round and oval to open and vesicular
- Nucleus and chromatin characteristics of chromatin are used as a standard reference when comparing dysplasia
- Usually stain blue
Superficial cells – MG05-45463
- The most differentiated squamous cells
- Nuclei are centrally located, small and pyknotic, or dense like “India ink-dots”
- The cytoplasm is abundant, thin, delicate and transparent
- Cell borders are well defined and have polygonal outlines
- Usually stain red
Metaplastic Cells- MG05-33763 and MG07-22283
- Parabasal-sized cells with dense cytoplasm and rounded cell borders
- Arranged singly or in a cobblestone pattern
- Thick and dense cytoplasm with sharply defined cell borders
- Nucleus is round to oval with a smooth membrane, centrally located
- Cytoplasm usually stains blue-green
Glandular Cells (2 Types)
Endocervical Cells – MG06-11492
- Tall and columnar
- Relatively abundant delicate cytoplasm
- Can be seen singly or in strips or sheets
- “Honeycomb” appearance, orderly arrangement
- Nucleus is round to oval with open, vesicular chromatin, eccentrically located
Endometrial Cells – MG05-45830, MG05-43590, and MG05-39644
- Spontaneously exfoliated endometrial cells are normally present only in the first half of the menstrual cycle (up to day 14)
- Smaller than endocervical cells
- Nuclei usually appear degenerated, eccentrically located in the cell
- Cytoplasm is generally scant
- Usually exfoliate in crowded, 3D groups
- Cells are often crowded and hyperchromatic
- Cautious with shedding of emc’s in women over 40 and postmenopausal women. Abnormal shedding of emc’s carries an increased risk of endometrial neoplasia
Transformation Zone
- The presence of endocervical cells and or metaplastic cells is two measures of the adequacy of a Pap smear, indicating the TZ has been sampled
- Sampling of the TZ allows for proper cancer surveillance because most cervical neoplasia is most likely to arise in the TZ
- Not necessary for smear to be “Satisfactory for Evaluation”…if there is no TZ sate in comments after stating sat for evaluation “The presence of an endocervical component/TZ component is absent”
Organisms
Candida – MG06-06998 and MG05-33589
- Associated with a change in vaginal glycogen, flora, or pH
- Pseudohyphae (sticks) and yeast (stones)
- “Spear” through epithelial cells – “shish kebab”
- Pseudohyphae stain red to grey-brown
Trichomonas – MG06-9701, MG05-46452, and MG06-12497
- Oval or pear-shaped organism
- Can range in size from an intermediate nucleus to a parabasal cell
- Nucleus is thin and elliptical – must be identified to diagnose trich!
- Trich causes slighly enlarged, dark nuclei and perinuclear halos in cells
Actinomyces – MG05-44099 and MG07-02558
- Strongly associated with IUD use
- Long, thin, filamentous bacteria that are reddish, branch and radiate from a central area
- Often referred to as “dust bunnies”
Herpes – MG05-45052 and MG05-24402
- Nuclei have a “ground glass” appearance
- Peripheral margination of chromatin
- May have dense eosinophilic intranuclear inclusions
- Large multinucleated epithelial cells with molded nuclei, or mononucleated cells with the nuclear features of herpes
ASCUS – G13-13495
- Nuclei are approximately 2.5-3x the size of an intermediate nucleus
- Slightly increased ratio of nuclear to cytoplasmic area (N/C)
- Minimal nuclear hyperchromasia and irregularity in chromatin distribution or nuclear shape
LSIL – G13-16504, G13-13562 and G13-16482
- Nuclear enlargement more than 3x the size of an intermediate nucleus
- Cells occur singly and in sheets
- Usually occur in cells with superficial-type cytoplasm
- Binucleation and multinucleation are common
- Chromatin is often uniformly distributed, but coarsely granular; alternatively, the chromatin may appear smudged or densely opaque
- Koilocytosis – perinuclear cavitation, consisting of a sharply delineated clear perinuclear zone and a peripheral rim of densely stained cytoplasm is characteristic but not required for LSIL.
HSIL – CASE TBD
- Cytologic changes affect cells that are smaller and less “mature” than the cells in LSIL
- Occur singly, sheets or in syncytial-like aggregates
- Nuclear hyperchromasia is accompanied by variations in nuclear size and shape
- Chromatin may be fine or coarsely granular and evenly distributed
- Contour of the nuclear membrane is quite irregular with grooves or indentations (popcorn)
- Increased N/C ratio
Squamous Cell Carcinoma – MG08-1496, MG09-16808 and MG09-29740
- Relatively few cells present, often as isolated single cells and not aggregates
- Marked variation in cell size and shape is typical, with caudate and spindle cells that frequently contain dense orangeophilic cytoplasm
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