Pap smear Examination

Oct. 26, 2018

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Pap smear Examination

  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
  15. LSIL Mature squamous cells with enlarged nuclei Koilocytosis or perinuclear cavitation Binucleation/multinucleati on is common Variable size nuclei
  16. Final Impression • ASC--H
  17. • 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.
  18. • USG: Normal study, No obvious mass/focal lesion in Cervix. • PAP smear
  19. Low power • Adequate smear • Moderate to dense inflammation
  20. • BB shots
  21. Low power • A syncytial cluster or hyperchromatic crowded group
  22. • High N:C ratio • Nuclear irregularity • Hyperchromatic • No nucleolus
  23. • Variable nuclear enlargement • High N:C ratio • Irregular nuclear margin • delicate cytoplasm
  24. • Isolated single abnormal cell
  25. • Abnormal, large stripped nuclei are seen that are considerably bigger than the intermediate cell nuclei.
  26. Differential Diagnosis • HSIL • Non- keratinized Sq cell Ca • Endocervical adenocarcinoma in situ (AIS) • Mimics of HSIL
  27. 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
  28. 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
  29. Sq cell Ca v/s HSIL
  30. Endocervical Adeno Ca in situ Hyperchromatic crowded cells with: • Glandular differentiation • Columnar cells • Strips and rosettes • Psuedo stratification • Snake eating an egg appearance • Feathering
  31. • Rosettes are highly characterestic of AIS and are never seen with HSIL
  32. • Resemble HSIL but feathering at borders gives away the glandular nature
  33. Impression • HSIL • Biopsy was advised
  34. • A cervical biopsy was sent for HPE (5325/15) on 20/6/15. • Imp: Carcinoma in situ of Cervix
  35. Low power • The abnormal immature cells show minimal maturation • from the base of the epithelium to the surface with nuclear size and shape variation
  36. Low power
  37. High power
  38. Low power
  39. • Dysplasia • Koilocytic changes
  40. High power • Koilocytic change • Dysplastic cells
  41. Impression • Carcinoma in situ cervix
  42. Mimics of HSIL/ASC-H
  43. Immature squamous metaplasia :-- Nuclear uniformity, smooth nuclear borders, and fine and evenly distributed chromatin
  44. Single benign endocervical cells are prone to cytoplasmic lysis
  45. Tubal metaplasia with Cilia
  46. 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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