mgh:cyto-week1-4

Lectures

• Lecture: ASCUS cytology by Dr. D. Wilbur
• Lecture: Squamous intraepithelial lesions by Dr. D. Wilbur

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