This document summarizes the Pap smear examination results of a 39-year-old HIV-positive female patient. On initial examination, the patient was found to have an inflammatory smear with a high nuclear-to-cytoplasmic ratio and irregular, hyperchromatic nuclei. This was assessed as atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H). On follow up, a syncytial cluster was seen with similar abnormal cellular features, leading to a diagnosis of high-grade squamous intraepithelial lesion (HSIL). A cervical biopsy confirmed carcinoma in situ of the cervix. The document discusses the criteria used to make these assessments and differentiate HSIL from

1. PAP Smear examination
Vikram Prabhakar (DCP,DNB Pathology)

2. Patient details
• Pt is a 39 yr female, a housewife
• HIV positive since 2001
• Is on Regular ART

3. H/O present illness
• Pt visited gynecology OPD in December 2014
for a routine examination.
• No h/o dysmenrrhoea, white discharge p/v.
• No h/o irregular menstruation.
• No h/o chronic disease
• No h/o blood transfusion or surgery

4. Obstetric history:
P1L1, FT ND, male child, 19 yrs back
Menstrual history:
Regular cycle of menstruation
Menarche at 13 years

5. On Examination
P/A– Soft, non tender, no organomegaly
P/S– Cervix, Vagina healthy
P/V– uterus normal size, AV, FF, NFT
RS/CVS/CNS– NAD
PAP smear was done

6. Low power
• Adequate
• Inflammatory smear

7. Low power view
• Inflammatory smear

8. High power
• High N:C ratio
• Irregular nuclei
• Coarse chromatin

9. • High N:C ratio
• Irregular nucleus
• Hyperchromatic nucleus

10. Differential diagnosis
• ASC-h/HSIL
• ASCUS
• LSIL
• ASC-H mimic

11. ASC
Squamous
differentiation
High
N:C
ratio
Nuclear
changes

12. ASCUS
>90%
ASC-H
<10%
ASC

13. Criteria for ASC-H
• Cells are the size of a metaplastic cells with
nuclei 1.5 to 2 times the size of normal.
• Variable N:C ratio; may be very high
• Prominent nuclear irregularity
• Generally hyperchromatic nuclei but may be
normo- or hypochromatic.
• Lack of nucleoli

14. ASCUS
• Nuclei are 2.5 to 3
times the nucleus of a
normal intermediate Sq
cell or twice the size
• of a squamous
metaplastic cell nucleus
• Slightly increased N:C
ratio
• Minimal nuclear
hyperchromasia

16. LSIL
Mature squamous cells
with enlarged nuclei
Koilocytosis or perinuclear
cavitation
Binucleation/multinucleati
on is common
Variable size nuclei

17. Final Impression
• ASC--H

18. • Revisited the OPD on 30th May 2015.
• No specific gynecological complaints.
On examination:
P/A : soft, non-tender
P/S : Cx, vagina healthy
P/V : uterus normal size, FF, NFT.

19. • USG: Normal study, No obvious mass/focal
lesion in Cervix.
• PAP smear

20. Low power
• Adequate smear
• Moderate to dense
inflammation

21. • BB shots

22. Low power
• A syncytial cluster or
hyperchromatic
crowded group

23. • High N:C ratio
• Nuclear irregularity
• Hyperchromatic
• No nucleolus

24. • Variable nuclear
enlargement
• High N:C ratio
• Irregular nuclear margin
• delicate cytoplasm

25. • Isolated single
abnormal cell

26. • Abnormal, large
stripped nuclei are seen
that are considerably
bigger than the
intermediate cell nuclei.

27. Differential Diagnosis
• HSIL
• Non- keratinized Sq cell Ca
• Endocervical adenocarcinoma in situ (AIS)
• Mimics of HSIL

28. Criteria for HSIL
• Variable N:C ratio; may be very high
• Nuclear membrane notching and marked
irregularity
• Generally hyperchromatic nuclei but may be
normo- or hypochromatic
• Occasional mitosis
• Inconspicuous nucleoli
• In clusters-- Horizontal arrangement of cells at
periphery

29. Non keratinizing
Sq cell Ca
Pleomorphic
cell shapes
Tumor
diathesis
Prominent
nucleoli
Irregular
chromatin
distribution
HSIL
Coarse evenly
dispersed
chromatin
No tumor
diathesis
No nucleoli

30. Sq cell Ca v/s HSIL

31. Endocervical Adeno Ca in situ
Hyperchromatic crowded
cells with:
• Glandular
differentiation
• Columnar cells
• Strips and rosettes
• Psuedo stratification
• Snake eating an egg
appearance
• Feathering

32. • Rosettes are highly
characterestic of AIS
and are never seen with
HSIL

33. • Resemble HSIL but
feathering at borders
gives away the
glandular nature

34. Impression
• HSIL
• Biopsy was advised

35. • A cervical biopsy was sent for HPE (5325/15)
on 20/6/15.
• Imp: Carcinoma in situ of Cervix

36. Low power
• The abnormal
immature cells show
minimal maturation
• from the base of the
epithelium to the
surface with nuclear
size and shape variation

37. Low power

38. High power

39. Low power

40. • Dysplasia
• Koilocytic changes

41. High power
• Koilocytic change
• Dysplastic cells

42. Impression
• Carcinoma in situ cervix

43. Mimics of HSIL/ASC-H

46. Immature squamous metaplasia :-- Nuclear uniformity, smooth nuclear
borders, and fine and evenly distributed chromatin

47. Single benign
endocervical cells are
prone to cytoplasmic
lysis

48. Tubal metaplasia with
Cilia

49. HSIL in Atrophic smear
HSIL in atrophy may be difficult to distinguish from clusters of benign
atrophic squamous cells. Focusing in different planes allows one to
better distinguish them from the parabasal cells in the background

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