Maj Liv Eide Non-neoplastic gynaecological cytology

Non‐neoplastic
gynaecological cytology
Maj Liv Eide, Dep. of Pathology and Medical Genetics,
Trondheim University Hospital ans Dep. of Biomedical Science,
Soer‐Troendelag University College, Norway Agenda
 Satisfactory smear
 Normal cells in cervical specimens
 Inflammatory conditions in general
 Persistent irritation
o Metaplasia, tissue repair, tubal metaplasia, parakeratosis, radiation therapy, IUD changes, reactive endocervical cells
and chronic inflammation
 Specific infections
o Bacterial vaginosis, Candida albicans, Actinomyces Israeli, Trichomonas vaginalis and Herpes simplex virus
Satisfactory smear
Conventional cytology
 Conventional smear should have a minimum of approx. 8000 – 12000 well‐preserved and well‐visualized squamous cells.  The number shall be estimated, not counted
Liquid based cytology
 Liquid based preparations should have at least 5000 well‐visualized and well‐
preserved squamous cells.  A minimum of 10 fields should be counted along a diameter of the circle including the centre Minimum squamous cellularity in LBC Counting 10 fields: The average cell number per microscopic field to achieve 5000 cells is shown in the following table FN 20 ocular/
10X objective
FN 20 ocular/
40X objective
FN 22 ocular/
10X objective
FN 22 ocular/
40 X objective
cells/fields
cells/fields
cells/fields
cells/fields
13 mm (SurePath)
118,3
7,4
143,2
9,0
20 mm (ThinPrep)
50
3,1
60,5
3,8
Preparation
diameter (mm)
This method of strict criteria must not be applied to cell clustering, atrophy and cytolysis
Cervix: Normal cytology and hormones
•
Papanicolaous staining method
•
Estrogen and progesterone
Superficial squamous cells
 Polygonal cells with pink, transparent cytoplasm and centrally placed small, dark
(pycnotic) nuclei
 N/C ratio approx 1:30
 Influenced by estrogen
 Ovulation
Intermediate squamous cells
 Polygonal cells with light
blue/turqoise cytoplasm and a centrally placed, vesicular nuclei
 Nuclear size equals polymorphs
 Glycogen
 N/C ratio approx 1 : 20
 Influenced by progesteron
 2.half of menstrual cycle
 Pregnancy
Lactobacillus and cytolysis
•
Lactobacillus – rod shaped bacteria
•
Able to lyse glycogen‐ rich intemediate cells
•
Converts glycogen to lactic acid •
Second half of menstrual cycle and pregnancy
Parabasal squamous epithelial cells
 Round cells with bluegreen
cytoplasm and rund to oval nuclei
 N/C ratio: 1 : 5
 Atrophy
 Postmenopause
 Postpartum, when breast feeding
(some parabasal cells with
glycogen)
 Oral contraceptive pills
(progesteron)
Endocervical columnar cells
 Columnar shaped cells when viewed from the side
 Either secretory or ciliated cells
 Secretory cells with mucin vacuoles (one single or many)
 Ciliated cells have denser cytoplasm (bluegreen)
 N/C ratio: approx. 1 : 3
 Single, strips or in sheets (honeycomb pattern)
Endometrial cells
•Epithelial and stromal cells
•The nuclei of epithelial cells are the size of intermediate squmaous cells with
coarse chromatin due to degeneration
•Scant cytoplasm, often finely vacuolated
•Spontanously shedded endometrial cells: A double contour cell ball with centrally placed stroma surrounded by epithelium
•Endometrial cells shed after day 10‐14 or in the menopause is considered abnormal
Metaplasia – normal physiologic process
Squamoucolumnar
junction
Transformation zone
‐ histology
Metaplastic cells ‐
cytology
Metaplastic process: Reserve cell hyperplasia, immature squamous metaplasia and mature squamous metaplasia. Replaces damaged endocervical, columnar cells.
Squamous metaplastic cells
Immature
 Parbasal‐like cells
 Cobblestone pattern or single
 Thick, dense blue‐green cytoplasm with thicker ectoplasm
 ”Spider cells” due to forcibly scarped cells
 LBC: Can look like endocervical cells or HSIL
Mature
 Intermediate squamous‐like cells
 Rounded cell outlines
 Slightly, dense cytoplasm
 Remnants of cobblestone
Squamous metaplasia
Conventional
LBC
Euplasia – normal activity
Round to oval nuclei
Finely granulated chromatin
Evenly distributed and thin and even chromatinic rim
Uniform nuclei
Fra Compendium in Clinical Cytology, R.Mecsei
Cell damage
Inflammatory reaction with degenerative changes, thereafter
regenerative/reactive changes or cell death
Retroplasia
• Variation in nuclear size
• Loss of water control
•
•
Swelling of nuclei due to increased water intake
Wrinkled nuclear membrane due to loss of water
• Blurred or clumped chromatin • Eosinophilia
• Amphophilia
• Vacuolisation • Halo
Infection > decreased activity
Degenerative changes:
 Blurred or clumped chromatin
 Halo
 Amphophilia
 False eosinophilia
 Vacuolisation
Necrosis
Irreversibel exogene cell damage > death
Karyopycnosis
Karyorrhexis
Karyolysis
The cells burst in the end and the cell content leaks into the tissue, creating an inflammatory response unlike apoptosis.
Tissue repair
Repair is visualised as regenerative cells
Often seen in patients with recurrent cervicitis or after biopsies and laser therapy
Nuclear variation in size, shape and enlargement
Prominent nucleoli and finely granulated, evenly distributed chromatin, but not hyperchromatic
Abundant cytoplasm and cohesive cells in sheet‐like arrangements
Leukocyte infiltration in groups
Tubal metaplasia (TM)
Benign, nonneoplastic replacement of columnar cells (endocervical or endometrial) Cells characteristic of the fallobian tube
Usually occurs high up in the endocervical canal and common finding due to use of endocervical brush
Hyperchromatic crowded groups and stratified strips with high N/C ratio and dark, but finely granular, even chromatin
The finding of terminal bars and cilia is most helpful in recognising tubal metaplasia
Radiation damage
The cytological changes due to
radiation can be transitory, last for 1‐2 years or persist. Both tumour cells and normal cells are affected but tumour cells usually clear rapidly (6‐8 weeks)
http://nih.techriver.net/atlas.php
>Cytological criteria
Enlarged nuclei often multiple, pale or dark with N/C ratio relatively unchanged. Cytoplasm with amphophilia
Vacuolated cytoplasm (acute radiation change)
Repair/regeneration is common
IUD changes
Chronic irritation due to IUD tail and body affecting the tissue
> Cytological criteria
Reactive glandular (endocervical or endometrial cells) or metaplastic cells with prominent nucleoli and hypervacuolisation (“bubble‐gum cells”). Hyperplastic endocervical, columnar cells may form papillary tissue fragments.
A few, atypical appearing, single endometrial cells (IUD cells) or shed in clusters.
Clean background
The Pap Test by RM DeMay, ASCP Press 2005
Parakeratosis
Benign keratotic reaction, but may conceal underlying lesion, most often associated with condyloma or SIL. > Cytological criteria
Single, flat cells, layered strips of cells or concentrically arranged “pearls”. Usually orange stained cytoplasm and centrally, pycnotic and hyperchromatic nuclei. The Pap Test by RM DeMay, ASCP Press 2005
Reactive endocervical cells
Reactive endocervical cells are common (hyperplasia, polyps, cervicitis)
>Cytological criteria
•Cells ” lay flat” with enlarged, round to oval nuclei up to 4‐5 times the normal area
•Fine chromatin
•Bi‐ and multinucleation
•Prominent nucleoli
•Maintained N/C ratio
•Well defined cell borders
The Pap Test by RM DeMay, ASCP Press 2005
Chronic (follicular) cervicitis
Follicular cervicitis, synonymous with lymphoid cervicitis is an inflammatory condition involving lymphoid follicles in subepithelial areas. Associated with Chlamydia infection
> Cytological criteria: Mature and immature lymphoid cells along with tingible body macrophages, which must be identified. Follicular cervicitis is easier to interpret in conventional smears than LBC due to lymhocytic
dispersion in the latter. DD: Lymphoma, endometrial cells, histiocytes, metastatic tumor
cells.
Chronic (follicular) cervicitis
Conventional
LBC
Bacterial vaginosis
•
•
•
Thin, homogenous discharge Vaginal ph > 4,5 due to lack of lactobacilli Gardnerella vaginalis, one of the
major species assosiated with
bacterial vaginosis
> Cytological criteria
1. Clue cells: Coccobacillus sticked to squamous cells
2. Lack of inflammatory cells and lactobacilli
Fungal infection > due to Candida
Conventional
LBC
Pseudohyphae (sticks) and yeast (stones), which may look like “balloon dogs”. Budding may be seen. The pseudohyphae usually stain pale pink or blue and are surrounded by a small, clear halo. > Cytological criteria: Mildly enlarged nuclei, with slight hyperchromasia and hyperkeratosis: Lysed neutrophils are common. DD: ASC‐US
Actinomyces israeli Conventional
LBC
Actinomyces is associated with IUD usage
Actinomyces are branching, filamentous bacteria and in Pap test the bacteria live symbiotically with colonies of bacteria forming dark‐blue masses with spidery legs (actinomyces)
Trichomonasinfection
Conventional
LBC
Trichomonas vaginalis is an oval or pear‐shaped protozoan. The nucleus of the trichomonas is thin, pale and eccentrically located and must be seen to identify this organism. Flagella may be seen in LBC.
Cytological changes: Pseudokeratinization, amphophilia and false eosinophilia. Slight nuclear enlargement, hyperchromasia and perinuclear halos are common.
Herpes simplex virus infection
Conventional
LBC
http://nih.techriver.net/atlas.php
Multinucleated cells with enlarged nuclei and molding. The chromatin marginates due to viral particles filling the nuclei, resulting in ground glass appearance. The nuclear membrane appears thickened due to condensed chromatin. Intranuclear inclusions are highly characteristic when present, but is found only in half of the cases. Workshop
 Cases with both Conventionals and LBC (ThinPrep)and a number of cases with LBC Surepath only and ThinPrep
only
 NILM – negative for intraepithelial lesion or malignancy
 Please follow the arrows when passing the slides around