Pap smear cytology, screening and reporting

1. Presenter : Dr G Santhi priya
Moderator : Dr Prashanth R
7/19/2017 1Seminar

2. Contents
 Introduction
 Cervical cancer screening
 Sampling and preparation
 Bethesda system of reporting
 Normal cytology
 Abnormal cytology
7/19/2017 2Seminar

3. Dr George N. Papanicolaou
7/19/2017 3Seminar

4.  Method of cervical screening used to detect potentially
pre-cancerous and cancerous processes
 Embraced as an ideal screening test for preinvasive lesions ,
which , if treated would be prevented from developing into
invasive cancer
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5. Cervical cancer screening guidelines given
by ACOG and ACS/ASCCP/ASCP
Age to begin screening – 21yrs
‹21 yrs -should not be screened
Women aged 21 to 29 – Every 3 yrs with cytology
alone
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6. Women aged 30 to 65 – Every 3 yrs --cytology alone ,
Or
Every 5yrs --cotesting
Discontinuation - 65yr with adequate prior screening
and no history of CIN 2 or higher
Screening after total hysterectomy – Not recommended
7/19/2017 6Seminar

7. INSTRUCTIONS
 Schedule - 2 weeks after the first day of the last menstrual
period
 Avoid examination during menses
 Not to use vaginal medication, vaginal contraceptives,or
douches for 48 hours before the appointment
 Intercourse to be avoided before 24 hours
77/19/2017 Seminar

8. Speciment collection
 Key portion : squamo-
columnar junction
 Most likley site of dysplasia
 The sample should be obtained
before the application of acetic
acid or lugol iodine
 The spatula is rotated atleast
360 degrees
 An optimal sample includes
cells from the ectocervix and
endocervix
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9. PREPARATION METHODS
 Conventional smears
 Liquid – Based Cytology
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10. CONVENTIONAL SMEAR
 Samples are smeared directly
into a microscopic slide after
collection
 Smears often obtained using
spatula and brush
 Immediate fixation is critical
to prevent air drying artifacts
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11. 117/19/2017 Seminar

12.  Lateral wall of vagina
for hormonal assessment
 Posterior cul-de-sac is
the original papanicolaus
method.
 May contain endometrial
cells and cells from upper
reaches of genital tract7/19/2017 12Seminar

13. LIQUID BASED CYTOLOGY
 Manual/automated [Thin Prep/Sure Path/Mono Prep]
 Involves rinsing all the material into a fixative fluid
 Creats cell suspension , red blood cells are lysed by
the transport medium
 Processed in labouratory
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14. 14
Thinprep method
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15. Overcoming the inherent limitations of the
conventional pap smear
Conventional pap smear Liquid based cytology
 Majority of cells not captured
 Non-representative transfer
of cells
 Clumping and overlapping of
cells
 Obscuring material
 Virtually all cells of sample
are collected
 Ramdamized , representative
transfer of cells
 Even distribution of cells
 Minimizes obscuring
material
7/19/2017 15Seminar

16. THE BETHESDA SYSTEM
 Is a complete diagnostic system that recognizes the cytopathological
report as a medical consultation
 The first workshop was held in 1988
 Earlier versions of bethesda include 3 categories of adequacy:
Satisfactory
Unsatisfactory
Borderline.
 The 2001 Bethesda system eliminates the borderline category
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17. The 2014 Bethesda System
1. SPECIMEN TYPE
 Indicate conventional smear (Pap smear) vs. liquid-based
preparation vs. other
2. SPECIMEN ADEQUACY
 Satisfactory for evaluation
 Unsatisfactory for evaluation . . . (specify reason)
• Specimen rejected/not processed (specify reason)
• Specimen processed and examined, but unsatisfactory
for evaluation of epithelial abnormality because of (specify
reason)
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18. 3. GENERAL CATEGORIZATION (optional)
 Negative for Intraepithelial Lesion or Malignancy(NILM)
 Other
 Epithelial Cell Abnormality
The 2014 Bethesda System
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19. 4. INTERPRETATION/RESULT
 NEGATIVE FOR INTRAEPITHELIAL LESION OR
MALIGNANCY
Non-Neoplastic Findings (optional to report)
 Non-neoplastic cellular variations
• Squamous metaplasia
• Keratotic changes
• Tubal metaplasia
• Atrophy
• Pregnancy-associated changes
7/19/2017 19Seminar

20. Reactive cellular changes associated with:
• Inflammation (includes typical repair)
• Lymphocytic (follicular) cervicitis
• Radiation
• Intrauterine contraceptive device (IUD)
Glandular cells status post hysterectomy
7/19/2017 20Seminar

21. Organisms
• Trichomonas vaginalis
• Fungal organisms -Candida spp.
• Shift in flora - bacterial vaginosis
• Bacteria - Actinomyces spp.
• Cellular changes consistent with herpes simplex virus
• Cellular changes consistent with cytomegalovirus
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22.  OTHER
Endometrial cells (in a woman ≥45 years of age) (Specify if
“negative for squamous intraepithelial lesion”)
 EPITHELIAL CELLABNORMALITIES
SQUAMOUS CELL
 Atypical squamous cells
• of undetermined significance (ASC-US)
• cannot exclude HSIL (ASC-H)
7/19/2017 22Seminar

23.  Low-grade squamous intraepithelial lesion (LSIL)
(encompassing: HPV/mild dysplasia/CIN 1)
 High-grade squamous intraepithelial lesion (HSIL)
(encompassing: moderate and severe dysplasia, CIS; CIN 2
and CIN 3)
• with features suspicious for invasion (if invasion is
suspected)
 Squamous cell carcinoma
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24. GLANDULAR CELL
 Atypical
• endocervical cells (NOS or specify in comments)
• endometrial cells (NOS or specify in comments)
• glandular cells (NOS or specify in comments)
 Atypical
• endocervical cells, favor neoplastic changes
• glandular cells, favor neoplastic changes
 Endocervical adenocarcinoma in situ
 Adenocarcinoma
• endocervical
• endometrial
• extrauterine
• not otherwise specified (NOS)
7/19/2017 24Seminar

25. 5.OTHER MALIGNANT NEOPLASMS: (specify)
6.ADJUNCTIVE TESTING
7.COMPUTER-ASSISTED INTERPRETATION OF
CERVICAL CYTOLOGY
8. EDUCATIONAL NOTES AND COMMENTS APPENDED
TO CYTOLOGY REPORTS (optional)
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26. Normal cervical cells
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27. Superficial cells Intermediate cells
Parabasal cells Metaplastic cells
MICROSCOPIC APPEARANCE
Basal cells
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28. Superficial Cells
 Mature squamous cells
 Large polygonal
 Transparent pink cytoplasm
 Small, pyknotic nucleus
 5 to 6 μm in diameter.
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29. Intermediate cells
 Cyanophilic cytoplasm
 Pyknotic nucleus
 Granular chromatin
 Nucleus measuring 8 μm
in diameter.
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30. Parabasal cell
Basal cell
•Immature squamous cells
•Common at the transformation
zone
•Round or oval rather than
polygonal
•Variably sized nucleus
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31. Lactobacilli
 Lactobacilli are observed
in about 50% of normal
healthy adult female
population.
 Mainly affect intermediate
and superficial cells.
 Parabasal cells are
generally spared

32. • Mucin producing columnar
• Eccentrically placed nucleus
• Chromatin texture is finely granular
• Abundant vacuolated cytoplasm
• Arranged in cohesive sheets
• Honey comb appearance- sheets
• Picket fence appearance-strips
Endocervical cells
7/19/2017 32Seminar

33. NON NEOPLASTIC CELLULAR VARIATIONS
• Composed of parabasal
cells (immature squamous
cells)
• Interlocking parabasal
type cells represents
squamous metaplasia of
the endocervix
Squamous metaplasia
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34. Hyperkeratosis
• Anucleate squamous cells
• Protective response of the
stratified squamous epithelium-
chronic mucosal irritation
Parakeratosis
• Appears as plaques or as
isolated cells
• Keratinized squamous cells
with dense orangeophilic
cytoplasm & small pyknotic
nucleus7/19/2017 34Seminar

35. Tubal metaplasia
• Benign alteration of the
endocervical epithelium
Atrophy
• Hyperchromatic parabasal cells
• Flat monolayer sheet
• Preserved nuclear polarity
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36. Inflammation
SQUAMOUS EPITHELIAL CELLS
 Cytoplasm
vacuolation
perinuclear halo
abnormal keratinisation
 Nucleus
wrinkling of nuclear membrane
multinucleation
chromatin degeneration
ENDOCERVICAL CELLS
 Cytoplasmic degeneration
 Nuclear variation
7/19/2017 36Seminar

37. Trichomonas vaginalis
 Pear-shaped
 15 to 30 µm long
 Pale , eccentriacally placed
nucleus
 Red cytoplasmic granules
ORGANISMS
7/19/2017 37Seminar

38. Candida
 Fungal species – vulva ,
cervix and vagina
 Pink
 Yeast forms – 3 to 7 µm
diameter
 Long pseudohyphae and true
hyphae
Tangles and skewers of sq
epithelial cells around
pseudohyphae (spaghetti and
meatballs or shish kebabs
effect)7/19/2017 38Seminar

39. Bacterial vaginosis
 Steep reduction in proportion of
lactobacilli with concomitant
predominance of coccobacilli
 Short bacilli-coccobacilli,curved
bacilli,or mixed bacteria
 Layer of bacteria that obscures
the cell membrane (clue cells)
 Absence of inflammatory cells
with filmy appearance
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40. Actinomyces
 Long filamentous organism
 Tangled clumps of bacteria -
cotton ball appearance or
dust bunnies
 Center sulfur granule shows
amorphous material
 Periphery exhibits thin
filamentous bacilli radiating
outwards
 Intrauterine device (IUD)
usage.
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41. HERPES SIMPLEX
 Multinucleation
 Molding of nulcei
 Margination of chromatin
 Ground-glass nuclei
 Eosinophilic intranuclear
inclusions
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42. Epithelial cell abnormalities
Epithelial cell abnormalities
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43. 7/19/2017 43Seminar

44. 1.ASCUS : Atypical squamous cells of undetermined
significance
 Minimal hyperchromasia
 Bi-nucleation
 Even chromatin & enlarged
nucleus
 Multinucleated cells with
small perinuclear halo.
 -Mild nuclear enlargement
7/19/2017 44Seminar

45. 2.ASC-H : ATYPICAL SQUAMOUS CELLS -
CANNOT EXCLUDE HSIL
 Small cells with high N/C
ratio
 Smooth nuclear contour and
delicate chromatin
7/19/2017 45Seminar

46. 3.LSIL : low grade squamous intraepithelial lesion
 Includes HPV / mild dysplasia /
CIN1
 Intermediate sized cells
 Nuclear atypia-
enlargement
irregular contour
hyperchromasia
slight chromatin coarseness
 Cytoplasmic cavities (koilocytes)
 Keratinizing variant-deeply
orangeophilic cytoplasm and
squamous pearls Koilocyte
7/19/2017 46Seminar

47. 4.HSIL:High grade squamous intraepithelial lesion
 High N/C ratio than LSILs as the
cells are smaller usually parabasal
sized cells
 Discrete cells or syncytium like
groups-hyperchromatic crowded
groups
 Nuclear atypia-
enlargement
marked irregularity in countour
marked hyperchromasia
marked chromatin coarseness
 Karatinizing variant
7/19/2017 47Seminar

48. 5.Squamous cell carcinoma
 Most common malignant tumor
of cervix
 HPV 16 & 18
 HSIL features ,plus
macronucleolus
irregular chromatin distribution
tumour diathesis- granular ,
amorphous precipitate with
nuclear debris and RBC
Tad pole cells-bizzare
elongated spindle shaped cells
Fiber cells –keratinizing type
7/19/2017 48Seminar

49. 6.Adenocarcinoma in situ (AIS)
•Hyperchromatic crowded groups
•Glandular differentiation
columnar cells
strips and rosettes
feathering
•Neoplastic nucleus
hyperchromasia
crowding,stratification
inconspicuous nucleolus
apoptosis
mitoses
no tumour diathesis
7/19/2017 49Seminar

50. 7.Endocervical Adenocarcinoma
• Tumor diathesis- one half of cases
• Large,round nucleus
• Prominent nucleolus
• Abundant cytoplasm
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51. Conclusion
 The mortality rate from cervical cancer fell dramatically after
screening was introduced
 There was a direct correlation between the intensity of
screening and decrease in mortality
 Implementing Liquid Based Cytology will increase
oppurtunity to detect early signs of abnormality
 The Bethesda System (TBS) improve the predictive value of
the screening process
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52. Thank you ‼
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53. References
 Cibas E S, Ducatman B S.Cervical and vaginal
cytology.In: Cytology : diagnostic principles and clinical
correlates, 3rd ed.Elseiver;2008 p1-60.
 Solomon D, Nayar R. The Bethesda System for Reporting
Cervical Cytology.2nd ed.springer;2004
 Nayar a R, Wilbur B D C.The Pap Test and Bethesda
2014 .Acta Cytologica. 2015;59:121–132
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