Cytology, Exfoliative

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Cytology, Exfoliative

  1. 1. CYTOLOGYCYTOLOGYEXFOLIATIVEEXFOLIATIVE
  2. 2. a branch of Cytology which deals wit the microscopic study of cells thathave been desquamated from the epithelial surfaces.recommended for :Detection of malignant cells or precancerous lesions in the bodyDetection of asymptomatic or precancerous cervical lesions in womenAssessment of female hormonal status in case of sterility and endocrinedisordersDetermination of genetic (phenotypic) sexDetection of the presence of infectious microorganisms
  3. 3. CYTOLOGY SPECIMENS1. peritoneal, pericardial and pleural fluids2. CSF3. Nipple discharge4. Bronchial brushings / washings5. Sputum6. Gastric washings7. Urine sediment8. Prostatic secretions9. Cervicovaginal (paps) smear
  4. 4. • Collection Procedure:- Using standard paracentesis technique. A minimum of10 mL of specimen is desirable for optimal cytologicevaluation. Heparin may be added to the specimen toreduce clotting.- Place three (3) units of heparin per mL capacity ofthe collection container. Gently agitate to thoroughlymix the specimen and heparin.- Always Submit the specimen along with the completedcytology request form.- The specimen should be refrigerated until transported tothe lab.BODY FLUIDSBODY FLUIDS
  5. 5. A pleural smear
  6. 6. Pericardial fluid
  7. 7. CSF is usually obtained through a lumbar puncture(spinal tap).
  8. 8. • Gently strip the sub-areolar area and nipple with the thumb andforefinger.• Place the slide upon the nipple and draw it quickly across thenipple. ***If 1 drop is obtained, get another slide and do the pull-apart technique.• Immediately immersed the slide into a bottle of 95% isopropylROH or use spray fixative.NIPPLE DISCHARGENIPPLE DISCHARGE
  9. 9. a. bronchial washingb. bronchial lavagec. bronchial brushing
  10. 10. - Bronchoscopically-directed brushing of identified lesion.•Collection Procedure:- Using standard bronchoscopy technique, identify the lesion inquestion and obtain a brushing sample of the lesion.- Gently apply the sample on to glass slide and immediatelyimmerse slide into 3% glacial acetic acid alcohol fixative.- The brush tip should also be cut off into the solution.Bronchial Brushings
  11. 11. Bronchial Washings•Specimen:Bronchscopically-obtained washing (preferable at least10 mL) of the bronchi in the region of the suspected lesion.•Collection Procedure:-Using standard bronchoscopy technique, lavage thedistribution of the bronchus to be sampled.-Collect the wash in a clean container. Label thecontainer with correct patient information and
  12. 12. NORMAL-obtain at three consecutive morningsputum specimens by deep coughmethod.-Collect the sample in a wide-mouthcontainer containing Saccomano fluid(50% EtOH and 2% carbowax)INDUCED- Inhalation of aerosol solution for 20mins to produce deep cough sample.- Collect the sample in a wide-mouthcontainer containing Saccomano fluid(50% EtOH and 2% carbowax)
  13. 13. Washings (Esophageal, Gastric, Other)•Specimen: Endoscopically obtained washing (preferably at least10 mL) of the region of the suspected lesion.ProcedurePatient should fast overnight or for a minimum of six hours priorto the procedure.- Using standard endoscopy technique, lavage the area ofinterest using a physiologic solution. Aspirate the solution andplace in a clean container.- If transport of the specimen will be delayed more than four (4)hours, the specimen should be refrigerated until transported tothe lab.
  14. 14. The endocervical mucus will prevent air-drying duringcollection of the subsequent cervical component.Using the extended-tip spatula scrape material from thewhole circumference of the cervix.Withdraw the spatula and spread the collected materialquickly and evenly onto the slide .Fix Immediately .
  15. 15. smears should be from fresh materialsee requisition form (patient’s ID: name, age; date and type of specimenrequestedlabel the slide-Methods of Smear Preparation:1. streaking2. spreading3. pull apart4. touch or impression smear
  16. 16. STREAKINGused for preparing mucoid secretions vaginalsecretions, sputum and gastric content)use a spatula, dissecting needle or applicator stick andstreak in a zigzag fashion
  17. 17. SPREADING- used for thick mucoid secretions (smears of fresh sputum andbronchial aspirates)
  18. 18. PULL APART- for serous fluids, concentrated sputum, and enzymatic lavageform the GIT, smears of urinary sediment, vaginal pool and breastsecretions
  19. 19. TOUCH IMPRESSIONTOUCH IMPRESSIONImpression cytology beingImpression cytology beingcollected From a patient , usingcollected From a patient , usinga sterile glass slide with polisheda sterile glass slide with polishededges.edges.
  20. 20. FIXATIONexfoliated cells decompose rapidly which may destroy cellular andnuclear details, in turn will give inadequate results for diagnosis.•COMMON FIXATIVES1. equal parts of 95% EtOh and ether2. 95% EtOH3. Carnoy’s fluids4.equal parts of tertiary butyl alcohol and 1 part 95% EtOH5. SCHAUDINN’S FLUID – sat. aq. Hg2Cl, absolute HoAc6. MeOH – for dried films
  21. 21. 1. PAPANICOULAOU or Pap’s SmearAdvantage:- transparent blue staining of cytoplasm is observed- excellent nuclear staining- color range is predictable and of great value in identification ofcellsDisadvantage:- procedure is lengthy and complicated- does not give accurate acidophilic index
  22. 22. Stains for Pap’s:1. Harris Hematoxylin2. OG 6 StainOrange Green 6, 0.5 solution in 95% ROH 100 mlPhosphotungstic acid 0.015gm3. EA 50light green SF, yellowish 0.1% solution in 95% ROH 45mlBismarck brown 0.5 in 95% ROH 10 mlEosin Y, 0.5% in 95% ROH 45 mlPhosphotungstic acid 0.2 gmLithium Carbonate. Sat. aq. Solution 1 drop*** EA 50 is comparable to EA 36*** EA 65 differs from EA 50 or EA 36 only with respect to theconcentration of the light green stock solution
  23. 23. Procedure for Pap’s Stain:1. Fix in ether-ROH and pass thru 80% ROH, 40% ROH anddistilled H2O.2. Stain in Harris Hematoxylin for 4-5 minutes.3. Wash with H2O.4. Pass thru 0.25% HCl in 50% ROH.5. Immerse in 1.5% NH4OH in 70% ROH for 1 minute.6. Rinse in 70% ROH and pass thru 80% and 95% ROH.
  24. 24. Procedure for Pap’s Stain:7. Stain with OG 6 for 1.5-a minutes.8. Pass thru 3 changes of 95% ROH.9. Stain with EA 65 or EA 50 for 3 minutes.10. Pass thru 3 changes of 95% ROH.11. Dehydrate and clear in:a. absolute ROH,b. equal parts of ether and absolute ROH,c. 2 changes of xylol12. Mount in Canada Balsam.
  25. 25. Results:Cytoplasm – either bright red orgreenish bluevesicular nucleus – bluepyknotic nucleus – dark blue toblackbacteria – dark bluemycelia – violetTrichimonas vaginalis – palegreenish blue blob of cytoplasm
  26. 26. Cytoplasm – either bright red or greenish bluevesicular nucleus – bluepyknotic nucleus – dark blue to black
  27. 27. Trichimonas vaginalis – pale greenish blue blob of cytoplasm
  28. 28. Altered nuclear-cytoplasmic ratiosHyperchromasiaIncreased mitotic activityAtyical mitosesCHANGES IN MALIGNANCYCHANGES IN MALIGNANCY
  29. 29. Multinucleate cells– with irregular hyperchromatic or bizarre nuclei should be suspicious,Anisokaryosis– considerable variation in nuclear size and shape is common inmalignant cells.Giant single nucleus (polyploidy)– often seen in malignant cells, polypoidic cells may also occur in benignconditions, especially in thyroids of older women.
  30. 30. CYTOPLASMIC CHANGES- cells of squamous carcinomas frequently show a tendencyto cytoplasmic eosinophila.- adenocarcinoma cells may enclose, endometrial andcolonic cancers)- cytoplasmic vacuolation is common in adenocarcinomacells, but may be also be seen in endometrial cells followingcutterage.
  31. 31. In general:- malignant cells show reduced cohesiveness, possibly related to adefect of the intercellular “zippers” i.e., desmosomes.-Cancer cells are larger than their normal counterparts andfrequently show bizarre and grotesque shape.Occasionally:- exfoliated cells from epithelial tumors assume a greatlyelongated, fibrocyte-like appearance.
  32. 32. CELL PATTERN•Examine for the small groups or clusters of cells-Oblivious patternse.g. acini in adenocacinoma arising in glandular tissues-Rosettes in neuroblastomas and ependymoma-Stratification in squamous epithelial growths-Whorls in mesotheliomasIf there are no patterns focus up and down the on cellclumps-In strips epithelium, irregular stratification of anisokaryotic,hyperchromatic cells are helpful in diagnosing carcinoma ofcervix and bronchus.
  33. 33. OTHER CRITERIA1. In bronchial secretion smear, abundant lymphocytesare common in presence of malignancy, but may alsobe found in certain inflammatory conditions and inleukaemia.2. The presence of old blood and blood pigments is aminor indirect clue, but has many other etiologies.
  34. 34. VAGINAL CYTOLOGYVaginal cytology is a type of endocrine assay. Tracking changes inthe morphology of desquamated vaginal epithelial cells provides aconvenient means of assaying changes in estrogen levels.
  35. 35. •Vaginal smears may be taken regularly and often.•Hormonal changes are best mirrored in the upper third ofthe vagina.•They can also be taken from the lateral walls because theirmore accessible and less likely to be contaminated bycellular debris or discharge.
  36. 36. -SUP{ERFICIAL CELLS-Large (30-60u)-Polyhedral flat cells-Cytoplasm: may be acidophilic orbasophilic-Presence of small dark pyknotic nuclei(less than 6u)
  37. 37. Anucleate cells are abnormal which may be derived from:1. smear contamination by the cells from the vulva2. epidermization of the vagina or cervix resulting fromprolapse3. leukoplakia of the cervix4. ruptured membranes in pregnant women5. marked hyper-estrinism
  38. 38. INTERMEDIATE CELLS-medium large (20-30u)-Polyhedral or elongated-Cytoplasm: basophilic with vacuoles-Vesicular nuclei (6-9u)
  39. 39. - Boat-shaped intermediate cells with a strong tendency to fold andcurl their edges.- Expression of the combined estrogen-progesterone effect-found in the latter half of menstrual cycle, during pregnancy,menopause--may also be found as a result of abnormal androgen stimulation,either endogenous or exogenous
  40. 40. -PARABASAL CELLS-Round to oval cells-Smaller than intermediate (15-25 u)-Thick-“sunny-side up” like cells-Have strong basophilc cytoplasm andvesicular nucei (6-9 u )-Found from 2 weeks of age to puberty,after childbirth, abortion or miscarriagesand after menopause.
  41. 41. -ENDOCERVICAL CELLS-Slightly cylindrical appearance-occurs in groups and strips of threeor more cells-cytoplasm: deeply basophilic thethat of the parabasal cells
  42. 42. -ENDOMETRIAL CELLS-Found during menstruation period ( ingroups) and 1-4 days after the cessationof the period (single)-Endometrial stromal cells: seen in tightclusters of small, oval dark cells;Glandular cells: slightly larger.-Nucleus: small and moderately dark-Cytoplasm: basophilic and maybevacuolated
  43. 43. - “Lactobacillus acidophilus”-Gram + slender rod bacteria--Predominant organism of the vaginalnormal flora: establishes the low pHthat inhibits the growth of pathogens-Stains pale blue to lavender-Energy is obtained by thefermentation of glycogen derivedfrom disintegrating epithelial cells-Numerous in the luteal phase andduring pregnancy
  44. 44. CYTOLYSIS IN VAGINAL CYTOLOGY- Infection- estrogen-low vaginal pH (below 4.2)Occurs in the last trimester ofpregnancy, more common indiabetic patients shows large numbers ofnaked nuclei and very abundantDoderlein bacilli.
  45. 45. The BETHESDA SYSTEMSpecimen AdequacySatisfactoryLimitedUnsatisfactoryGeneral Categorization:Negative for Intraepithelial lesion or malignant cellEpithelial cell abnormalityDescriptive Diagnosis:Atypical squamous cells of unknown significanceLow grade squamous intraepithelial lesionHigh grade squamous intraepithelial lesionSquamous Cell CarcinomaGlandular cell abnormalityAtypical glandular cellsAdenocarcinomaOthers
  46. 46. Pap smear specimens are consideredsatisfactory for interpretation if there are:•Adequate numbers of well-visualizedsquamous cells present•Adequate numbers of well-visualizedendocervical cells or squamousmetaplastic cells (from the transformationzone).•Less than 50% of the cells obscured byblood or inflammation•Properly labeled specimensSpecimen Satisfactory
  47. 47. Pap smear specimens are consideredunsatisfactory for interpretation if thereare:•Inadequate numbers of well-visualizedsquamous cells present•Inadequate numbers of well-visualizedendocervical cells or squamousmetaplastic cells (from the transformationzone).•More than 75% of the cells obscured byblood or inflammation•Improperly labeled specimensUsually, these smears are recommendedfor repeat sampling.
  48. 48. Specimens subjected to rejection1. Specimen is submitted without a requisition.2. Specimen is not labeled with the patient name.3. The patient name (or other identifying information) on thespecimen and requisition do not correspond.4. The specimen is labeled appropriately but the requisition is notlabeled.5. The specimen slide(s) is (are) irreparably broken.6. Specimen is submitted from an unauthorized source.
  49. 49.  NEGATIVE FORNEGATIVE FORINTRAEPITHELIALINTRAEPITHELIALLESIONLESION
  50. 50. * Atypical squamous cells-of undetermined significance (ASC-US)-cannot exclude HSIL (ASC-H)Atypical squamous cell (ASC-US)
  51. 51. * Low grade squamous intraepitheliallesion (LSIL)(encompassing: HPV / mild dysplasia /CIN 1)Low GradeSquamousIntraepithelialLesion
  52. 52. •High grade squamous intraepitheliallesion (HSIL)(encompassing: moderate and severedysplasia, CIS, CIN 2and CIN 3)•- with features suspicious for invasion (ifinvasionis suspected)Severe Dysplasia or CIS
  53. 53. * Squamous cell carcinoma
  54. 54. Adenocarcinoma in situ of the cervix(upper left), next to normal glandularepithelium (lower right).
  55. 55.  EndometrialEndometrialcarcinomacarcinoma
  56. 56. REFFERENCESREFFERENCES Pathology.jhu.eduPathology.jhu.edu www.pathologyoutlines.comwww.pathologyoutlines.com icytologywordpress.comicytologywordpress.com er.wikipedia.orger.wikipedia.org

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