1-3 GYN Benign Cytology and Abnormal Squamous Lesions

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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